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Cases substantiated in FY17 3rd Quarter (April 1, 2017 - June 30, 2017)

County & Facility Name Issue(s) Type of City License (RN, LPN, CNA) Shiawassee Ovid Healthcare Failure to remove peg tube dressing resulting in 1 LPN Co.; Ovid Center mold formation.

Lack of discharge planning for three residents resulting in hospitalization for one individual 1 LLBSW and lack of coordinated services. Lack of documentation and follow-up for two residents involved in a physical altercation.

Wayne Co.; The Village of Overuse of 2 blood thinners, resulting in 1 MD Redford Redford multiple organ failure and death.

Berrien Co.; Silverbrook Failure to ensure residents received needed 1 NHA Niles Rehabilitation and services by properly trained staff; failure to Nursing Care assess failures of all staff who contributed to Center incident (resident death) and exacerbated the incident.

Failure to properly attach an ambubag to facilitate oxygen flow to an unresponsive resident. The resident died. 1 RN

Failure to suction tracheotomy tube to prevent blockages; falsifying documentation; failure to perform CPR on a resident who was not breathing. The resident died as a result. 1 LPN

Gratiot Co.; Ashley Care Center A staff member was caught stealing medication The facility Ashley and pain patches from residents. was cited for this. St. Joseph Heartland Health A resident was given medication without a 1 RN Co; Three Care Center, Three doctor's order and experienced a fall as a result Rivers Rivers of being groggy. The fall resulted in a hip fracture which directly contributed to the resident's death.

*Care facilities are hospitals, nursing homes, juvenile care facilities, adult foster care homes, rehabilitation centers and state psychiatric hospitals.