<p>Cases substantiated in FY17 3rd Quarter (April 1, 2017 - June 30, 2017)</p><p>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.</p><p>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.</p><p>Wayne Co.; The Village of Overuse of 2 blood thinners, resulting in 1 MD Redford Redford multiple organ failure and death.</p><p>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.</p><p>Failure to properly attach an ambubag to facilitate oxygen flow to an unresponsive resident. The resident died. 1 RN</p><p>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</p><p>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.</p><p>*Care facilities are hospitals, nursing homes, juvenile care facilities, adult foster care homes, rehabilitation centers and state psychiatric hospitals.</p>