Seven Sisters Living Center

Review of the two 6/27/24 SD DOH complaint reports revealed:

*Resident 1 had not received her Fentanyl (a controlled medication for severe pain) medication as ordered by her physician.

-She was supposed to have received a new Fentanyl topical patch every 72 hours (3 days).

*Her Fentanyl patch was applied on 6/8/24.

-It had not been replaced from 6/8/24 through 6/21/24.

*She did not receive four doses.

-She had increased pain and migraine headaches during that time.

*She had called a friend and was reported to have been crying because of her increased pain and migraine headaches.

2.

Interview on 7/23/24 at 9:23 a.m. with resident 1 revealed:

*She was receiving hospice care for end-stage kidney failure.

*She stated, I started having pain and looked at the calendar and found out it (Fentanyl patch) hadn't been changed in several weeks. It was supposed to be changed every three days.

-She stated she had increased back pain and severe migraine headaches during that time.

-She stated, It was a doozy for a few days. It was a hell of a migraine.

*She stated a hospice nurse told her the Fentanyl patch medication was prescribed correctly to indicate it would be replaced every 72 hours (three days), but the pharmacy had changed it to be replaced every 72 days.

435072

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 435072 B.

Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Seven Sisters Living Center 1201 Hwy 71 South Hot Springs, SD 57747