The findings of the complaint health survey (Intake #26488) conducted 1/26/21 through 2/9/21 are documented in this report. The survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
The sample was comprised of 4 current resident and 2 discharged residents. The facility had a census of 52 residents.
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
BIMS: Brief Interview for Mental Status
CAA: Care Area Assessment
CBG: capillary blood glucose or
blood sugar
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
CPR: Cardiopulmonary Resuscitation
DNS: Director of Nursing Services
F: Fahrenheit
FRI: Facility Reported Incident
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MAR: Medication Administration
Record
mcg: microgram
MDS: Minimum Data Set
mg: milligram
ml: milliliters
O2 sats: oxygen saturation in the
blood
OT: Occupational Therapist
PCP: Primary Care Physician
PO: by mouth, orally
PRN: as needed
PT: Physical Therapist
RA: Restorative Aide
RAI: Resident Assessment
Instrument
RD: Registered Dietician
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care
Manager
SLP: Speech Language
Pathologist
TAR: Treatment Administration
Record
tid: three times a day
UA: Urinary Analysis
UTI: urinary tract infection
The findings of the revisit complaint (Intake # 26488) health survey conducted 3/30/21 are documented in this report. The facility was found to be in substantial compliance with 42 CFR Part ยง483 Requirements for Long Term Care Facilities.
Based on observation, interview and record review, it was determined the facility failed to follow qualified mental health professional recommendations, to ensure interventions were in place and to provide adequate monitoring and supervision to ensure freedom from resident to resident verbal and physical abuse for 2 of 6 sampled residents (#s 1 and 3), This placed residents at risk for mental anguish, psychosocial decline, physical harm and continued abuse. Findings include:
The facility's 4/2015 policy titled " One on One Supervision Guidelines" indicates the following: ...the facility will provide [one on one supervision] for residents whose safety is at risk or for residents who are putting other residents at risk." The policy also indicates:
1. When the facility determine[s] that a resident is at risk of hurting themselves or someone else, one on one supervision will be assigned.
4. The facility will ensure that staff assigned to the one on one supervision has the education and support necessary to maintain the resident's safety as well as their own.
5. When a resident is assigned a [one on one], the assigned staff member may not leave the resident unattended. The nursing supervisor is responsible to ensure coordinated break periods so that the resident is not left unattended.
The facility's 7/2020 Abuse Prevention Policy and Procedure included: "Each resident has the right to be free from abuse... Residents must not be subjected to abuse by anyone, including but not limited to... other residents..." The policy defines abuse as "the willfully infliction of injury... intimidation, or punishment..." The policy goes on to define willful as used in the definition of abuse "means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm." The policy includes the following as examples of abuse:
a. Any physical injury to a resident, which has been caused by other than accidental means. This includes injuries that a reasonable and prudent person would have been able to prevent such as hitting, pinching or striking..."
e. Verbal abuse as prohibited by federal law, including the use of oral, written or gestured communication to a resident or visitor that describes a resident(s) in disparaging or derogatory terms.
Resident 3 admitted to the facility in 6/2019 with diagnoses including a stroke. Resident 3 was later diagnosed with vascular dementia with behaviors in 12/2019.
Review of Resident 3's facility "facesheet" indicates that Witness 2 (Son) is Resident 3's "responsible party." Further review of the resident's record revealed no indication Witness 2 had power of attorney or guardianship for Resident 3. The facesheet further indicated Resident 2's spouse to be listed as her/his emergency contact #1.
Review of Resident 3's current Kardex (in room care plan) did not indicate the resident had a diagnoses of dementia with behaviors. The Kardex further indicated Resident 3 was to have 15 minute checks, and for staff to ensure they completed the sheet provided for documentation. The Kardex further indicated to place the resident with a one on one staff "if needed."
Review of Resident 3's 6/1/20 through 1/30/21 Behavior Monitoring Record indicated the resident had a history of behaviors that included, hitting staff, cursing at staff and residents and refusals of care. The resident's behavior was to be documented every day, evening and night shift. The history of behaviors included hitting not only staff, but also residents, as well as her/his history of wandering and inappropriate touching. The document did not make clear how staff were to document what specific behavior the resident presented, such as using number codes to document specific behaviors by number. Interventions included in the document revealed the following number coded interventions and outcome codes:
Interventions:
1. Redirect, change subject of conversation.
2. Ensure ADL care needs met
3. Offer snack
4. Offer drink
5. Leave room and return
6. Have different staff assist
Outcome Codes:
+improved
- worsened
0 unchanged
1a. The 4/6/20 Quarterly MDS assessment indicated the following about Resident 3:
*Not cognitively intact with fluctuating disorganized thinking.
*Several days in which she/he was unable to stay asleep, or slept too much.
*1-3 days out of 7 days in which verbal or behavioral symptoms were directed toward others.
*Required assistance by one staff for all personal cares
*Received scheduled pain and anti-psychotic medication
Review of Resident 3's comprehensive care plan in place during the month of 6/2020 revealed the following focus, goals, and interventions:
*The resident had pain due to arthritis, neuropathy (numbness, weakness and/or nerve pain) and Fibro-myalgia (chronic widespread pain). Interventions included administration of prescribed pain medication and non-medical interventions such as diversional activities or repositioning for comfort.
*The resident could be resistive to medication or cares, had cognitive impairment, delusions and a history of false accusations of inappropriate touching. Interventions included approaching the resident calmly and unhurriedly, explain why care is needed before beginning care, if the resident resists care to leave her/him safe and return later to re-offer care.
*The resident had a history of hitting staff and other residents. Interventions included q 15 minute checks as well as assigning a one on one staff person if needed.
*The resident had a history of verbal aggression, cursing, using racial slurs with both staff and residents. Interventions included approaching the resident calmly, attempting to not invade her/his personal space, to not engage in arguments with the resident or become defensive, encourage activities the resident enjoys, ensure other residents are safe and remove them from the area ASAP if behavior/yelling/threats occur, keep schedule and routine as predictable as able, listen attentively, refer for mental health evaluation as indicated offer to play music or limit noise, listen attentively and attempt to re-focus behavior to something positive when resident is exhibiting verbally abusive behavior.
Review of Resident 3's 6/1/20 through 6/31/20 "15 minute check sheet" revealed all dates and times in which the resident was in the facility to be completed by various staff members.
Review of Resident 3's 6/1/2020 through 6/30/20 medication administration records indicated the following medications were prescribed and/or administered:
*3.8 MG Secuado Patch (antipsychotic) for psychosis/agitation associated with dementia was administered daily through 6/2020.
*25 MG Seroquel (antipsychotic) one time daily for hallucinations related to dementia with behaviors. The medication was refused five out of seven opportunities.
*125 MG Depakote sprinkles two capsules daily BID. The medication was refused 25 out of 58 opportunities.
*500 MG acetaminophen two tablets daily TID for pain. The medication was refused 39 out of 87 opportunities.
The 6/20/20 evening shift behavior monitoring record for Resident 3 indicated a behavior code of "2." It is unclear what this refers to, as Resident 3's behaviors listed on the document are not coded by number. Interventions documented to be used included 1-6. The outcome code noted was "-" which indicated the behavior worsened.
A 6/20/20 facility progress note at 5:29 PM completed by Staff 28 (Charge Nurse) indicated Resident 3 entered Resident 5 and Resident 6's shared room, and got into the bed of one of the residents. The note further indicated Resident 3 was verbally aggressive with the residents and with staff, and threw a small flashlight at Resident 5 which hit her/him in the nose. Staff 28 indicated she was directed by Staff 2 (DNS) to send Resident 3 out to the emergency department.
On 6/20/20 a facility investigation was initiated at 6:32 PM and signed as complete on 6/24/20. The investigation found Resident 5 and Resident 6 were in their shared room, when Resident 3 entered the room and was witnessed by staff to be verbally aggressive to both Resident 5 and Resident 6. Resident 3 was also witnessed by staff to be physically aggressive to Resident 5.
A 6/20/20 witness interview with Staff 27 (Former LPN) indicated Resident 3 was found roughly two hours prior to the 6/24/20 completed facility investigation, to be in the shared room of Residents 5 and 6 and to be cursing at them. There was no other indication in the investigation to indicate the allegation of verbal and physical abuse by Resident 3 towards Resident 5 and 6 was the second possible attempt of Resident 3 to be verbally aggressive toward Resident 5 and 6 on 6/20/20.
A 6/20/20 facility investigation interview with Resident 5 indicated she/he was hit in the nose with a mini flashlight by Resident 3. The resident stated she/he went into the hallway to call staff for help. Staff arrived and assisted and were able to remove Resident 3 from the room.
A 6/21/20 progress note at 1:57 AM by Staff 25 (LPN) indicated she received a call from the emergency department regarding the transport of Resident 3 back to the facility. Staff 25 indicated she questioned the hospital about the safety of Resident 3 to return to the facility for herself and for other residents. The charge nurse asked a care manager to call the emergency department who was also told Resident 3 was not admitted.
A 6/21/20 progress note at 5:39 AM by Staff 25 (LPN) indicated the resident returned from the emergency department at 3:45 AM. The note indicated the resident had not displayed any behaviors since her/his return. The note did not indicate if Resident 3 was assigned a one to one.
A 6/22/20 progress note at 5:27 AM by Staff 25 indicated Resident 3 was awake most of the shift, and needed a "[one to one] the first two hours of the shift." Resident 3 attempted to enter the shared room of Resident 5 and 6. The resident did not respond to redirection until a different "CNA" approached and distracted the resident "long enough to remove from doorway of other [Resident 5 and 6's room]." Resident 3 was noted to use foul language, and to yell and argue at "persons unseen" to staff. Resident 3 was assisted to her/his bed and was noted to "not get back out of bed" and "not leave room" after the incident. Resident 3 was noted to be in her/his room crying and sobbing, and then a few minutes later to be upset and yelling at staff, and attempting to hit staff. There was no indication if Resident 3 was assigned a one to one.
A 6/22/20 progress note at 12:12 PM by Staff 4 (Social Services) indicated she contacted Witness 2 "in regard to the resident needing a [higher level of care]. The note indicated Witness 2 was in agreement that the resident needed a higher level of care. Staff 4 indicated she would fax Resident 3's information over to a "behavioral unit" at another facility and informed Witness 2 she would let him know when she heard back from the behavioral unit facility. The note did not document or indicate if Resident 3's spouse and emergency contact #1 was contacted.
A 6/22/20 progress note at 12:38 PM by Staff 25 (LPN) indicated Resident 3 had outbursts of aggressive behavior that day, including attempting to throw her/his brief at someone. The resident was noted to have multiple episodes of "yelling and cussing and people who have attempted to check on [her/him]." Resident 3 was noted to have stayed in her/his room through the day thus far. There was no indication if Resident 3 was assigned a one on one.
Review of Resident 3's 6/22/20 Behavior Monitoring Record indicated a code of "10." It is unclear what this refers to, as Resident 3's behaviors listed on the document are not coded by number. Interventions documented to have been used by staff include 1-6. The outcome code noted was "-" which indicated the behavior worsened.
A 6/22/20 progress note at 7:11 PM by Staff 30 (LPN/Charge Nurse) indicated Resident 3 had "minimal aggression" during the shift and had a one on one in the room for "most of the shift." The note did not indicate what hours the one on one was or was not in the room.
A 6/23/20 progress note at 5:39 AM by Staff 25 indicated Resident 3 was in her/his bed during the entire shift, but only slept about one hour. The resident was placed with a one to one during the shift. Resident 3 was noted to cuss at staff, and also attempted to throw a television remote and a phone base at staff on different occasions through the shift. Staff were noted to "leave the room" when the resident became physically aggressive. The resident was noted to sleep about one hour during the shift. The note did not indicate if the one to one continued to monitor Resident 3 by way of "distant supervision" from the hallway.
A 6/23/20 progress note at 2:21 PM by Staff 28 indicated Resident 3's behavior was "okay" with one on one staff that day, but the resident refused all medications.
A 6/23/20 "note" by Staff 2 included in the 6/24/20 incident investigation included the following: " While resident has an ongoing [history] of labile behaviors that seem to cycle in intensity and focus the resident was doing fairly well with interventions implemented in the care plan. Distant supervision, quiet space and subtle redirect proved to be helpful to calm resident or at least change focus, less effective over the last few weeks." "Resident's chart had been reviewed by [Nurse practitioner] and meds adjusted recently [due to] refusal to consistently accept po medications."
A review of CNA day and night shift assignments from 6/20/20 through 6/23/20 revealed one example on 6/23/20 night shift of Resident 3 to be assigned a one to one CNA. The CNA was noted to be "1:1 with [Resident 3]" and to "help out" with two other documented rooms. There was no indication if anyone would cover for the CNA staff during their scheduled break.
A 7/17/20 PASSR Level 2 was completed to assess Resident 3 and the potential of her/him to be recommended for a higher level of care. The PASSR Level 2 indicated the facility "has placed [Resident 3] on [one on one] staffing "24/7" and stated the facility was not "staffed for this level of care..." The assessment described Resident 3 to have "unpredictable and endangering behaviors." The assessment indicated Resident 3's medical record included a letter from her/his medical care provider stating Resident 3 required "a higher level of psychiatric support than the facility is able or normally expected to provide" and also indicated the facility reported her/his son was now involved in her care and ""very cooperative."" The assessment indicated the facility had found placement for her/him in a memory care unit, but the placement was lost when Resident 3's spouse refused to allow her/him to be moved. The PASSR Level 2 went on to suggest the following recommendations be completed:
-"Recommend the facility work with [Witness 2] (Son) regarding timing and appropriateness of seeking legal guardianship, and indicated transition is often facilitated when "guardianship is in place." A phone number and website for a local resource were provided in the document to request information related to the guardianship process.
-Recommended the facility contact Witness 4 (Older Adult Behavioral Specialist) to present Resident 3's case to him and to request assistance from Witness 5 with the following:
a. Refer [Resident 3] to the Complex Case Committee to identify resources for referral and/or enhancement of services
b. Request information and assistance to request additional funding to cover the cost of [one on one] staffing in place for the safety of [Resident 3], other residents, and staff.
Observations made over day and evening shifts between 2/2/21 and 2/5/21, Resident 3 was observed to be in her/his room alone. The resident was not observed to display any behaviors. She/he was observed seated in her/his wheelchair, standing and looking out he window, and sleeping in bed. The resident was observed to have her/his door to the hall open at all times. An evening observation of Resident 3 revealed Staff 14 (CNA) to be entering the resident's room to complete a 15 minute check.
During Interviews with Witness 2 on 2/2/21 and 2/3/21 at 10:05 AM and 10:22 AM, he stated he did not believe the facility could provide Resident 3 with the correct level of care she/he needed, related to her/his behaviors. He further stated Resident 3's spouse had substance abuse issues, and the facility had informed him the resident's behaviors could be worse when her/his spouse was around. When asked why he was noted as the responsible party on Resident 3's facesheet, he was unable to answer, and further indicated he was not aware to be documented as such. Witness 2 stated he did not have power of attorney or legal guardianship of Resident 3. The witness stated he believed Resident 3's spouse had the ability to decline Resident 3 entering a new facility, and indicated a previous example of Resident 3's spouse refusing to allow her/him to be placed in a memory care facility she/he was accepted to. Witness 2 noted this had been a disappointment. When asked if Witness 2 ever had a conversation facilitated by the facility regarding the potential of working toward legal guardianship of Resident 3, he stated "no."
On 2/2/21 at 1:58 PM Staff 4 (Social Services) was asked about the recommendations in Resident 3's 7/17/20 PASSR Level 2. When asked why Witness 2 was listed as the responsible party on the resident's facesheet, she was unable to provide an answer. When asked if she had ever contacted Witness 2 to facilitate a conversation about the potential of him seeking legal guardianship for the resident, she stated "yes." She was asked to provide documentation to indicate the conversation occurred, and was unable to do so. When asked if she contacted Witness 4 as per the PASSR 2 recommendations, she stated she had not.
On 2/2/21 between 2:15 and 2:30 PM Staff 2 was made aware of the 2/2/21 interview with Staff 4. Staff 2 was also unaware of why Witness 2 was listed as Resident 3's resident representative and further indicated that Resident 3's spouse was not reliable and was often difficult to work with. Staff 2 acknowledged the suggested recommendations in the 7/17/20 PASSR Level 2 were provided to help ensure all measures have been taken by the facility to ensure the quality of life and safety of Resident 3, fellow residents and staff. Staff 2 was given an opportunity to provide documentation regarding the potential that Witness 2 was contacted specifically related to the potential to attempt to gain legal guardianship and to provide information if Witness 4 had been contacted. Staff 2 was unable to provide the requested documentation.
On 2/3/21 at 11:42 AM Witness 4 was asked if he had been contacted by the facility following Resident 3's 7/17/20 PASSR Level 2 being completed. Witness 4 stated he had not been contacted by the facility regarding the recommendation until 2/2/21.
On 2/4/21 Staff 14 (CNA) was observed to attempt to exit Resident 3's room. Staff 14 indicated she was just checking on Resident 3, who was sleeping in bed. She indicated staff complete frequent checks on the resident. When Staff 3 was asked if she/he was aware if the resident was ever required to have a one on one staff person, she indicated she had not been made aware. Staff 14 further indicated she did not know Resident 3 had a diagnoses of dementia with behaviors. When asked how she would be made aware of a resident's diagnoses of dementia with behaviors, Staff 14 indicated she would rely on the Kardex (in room care plan).
On 2/5/21 at 3:51 PM Resident 6 was observed to be in her/his room with the door open. The resident was asleep.
On 2/5/21 at 3:54 PM Resident 5 was observed to be up and seated in her/his wheelchair watching television. Resident 5 was asked if he/she recalled the incident on 6/20/20 that involved alleged verbal and physical aggression by Resident 3. Resident 5 had a difficult time recalling the incident, but was able to recall after a few minutes of talking. The resident did not recall being hit in the face by any objects thrown by Resident 3, but she/he did recall having water thrown on her/him by Resident 3. Resident 5 was asked if she was fearful of Resident 3 at the time of the incident, or at this time in the facility. Resident 5 indicated she/he did not feel fearful of the resident at that time, because "[she/he] was not alone in [her/his] room." She/he further stated she did not feel unsafe in the facility or fearful of Resident 3 at this time.
On 2/5/21 at 4:20 PM Staff 7 (Resident Care Manager) was interviewed. Staff 7 was asked to locate the current 2/2020 behavior monitor in place for Resident 3. When asked if the documented behaviors on the document were numbered, so that staff could code them in regard to a specific behavior, she stated no. When asked if the document made clear the resident had a behavior of not only hitting staff but also hitting residents, she stated no. Staff 7 acknowledged the way in which the behavior monitor read, and was to be filled out, did not lend to it being an accurate tool for staff when assessing Resident 3's behaviors or psychiatric medications during quarterly psychotropic review meetings. When asked if Resident 3 is ever placed on one one ones, Staff 7 stated "we try whenever we can because [she/he] is unredictable." When asked where one on one staff are documented when they are assigned to resident's, she stated "maybe the CNA schedule" and further stated she was "not sure if it gets written down." When asked if she was aware who Resident 3's responsible party was, she stated she believed the resident to be her/his own responsible party. Staff 7 further stated she believed Staff 4 was "looking into who [her/his] responsible party is."
On 2/5/21 at 4:55 PM Resident 3 was observed to be in her/his bed. Staff 31 (CNA) was observed to exit the resident's room. When asked what care Staff 31 provided, she stated she had just checked in on the resident, and stated the resident was asleep. Staff 31 stated she was very new to working this unit as a CNA. When asked if she had ever been made aware of Resident 3's history of aggression or behavior, she stated "no." Staff 31 stated Resident 3 preferred to be alone, and she was aware the resident was on 15 minute checks. she stated that all staff would share in this task, and it was not assigned to only one staff member.
On 2/8/21 Resident 5 was observed to be in her/his room and to be seated in her/his wheelchair watching television. The door to the hall was open.
On 2/8/21 Resident 6 was observed to be in her/his room and to be in bed sleeping, with her/his privacy curtain drawn back. The door to the hall was open.
On 2/8/21 at 10:37 AM Resident 3 was observed to be in bed asleep. The resident was in her/his room alone, with the door to her/his room open.
On 2/8/21 at 10:45 AM Staff 18 (CNA) was observed to walk past Resident 3's room on the A-Wing hall. Staff 18 was asked what her knowledge of Resident 3's potential behaviors or cares needs related to her/his behavioral health might be. Staff 18 indicated the resident had behaviors that could be verbally or physically aggressive. Staff 18 indicated Resident 3 had some increased behaviors the evening before and she/he had been placed on a one to one for this reason. Staff 18 confirmed there was not a staff person in the resident's room at this time, and stated the resident's one on one might be on break. Staff 18 said that due to Resident 3's unpredictable behavior it could be difficult to to tell when the resident might need a one on one.
Review of the 2/8/21 CNA A Wing Day Shift Assignment sheet indicated Staff 19 (CNA) was assigned as Resident 3's one to one. Staff 19 was documented to have a break at 10:30. The document did not indicate if anyone was assigned to replace her as Resident 3's one to one.
On 2/8/21 at 11:09 AM Staff 19 was observed to return to Resident 3's room entrance. Staff 19 was asked what her assignment was for this shift. Staff 19 indicated she was assigned as a one to one for Resident 3, unless she was needed to help out on the floor. The staff person further stated Resident 3 was asleep, which meant she did not need to be in the room at all times, but rather needed to keep an eye out for the resident. Staff 19 confirmed she went to break and did not have an assigned staff person scheduled to cover for her one to one assignment.
On 2/8/21 at 11:25 AM Staff 12 (Resident Care Manager) was interviewed. Staff 12 was asked about the expectation of one to one staff when breaks occurred, or when they were assigned to watch a resident. Staff 12 indicated that when a staff had a break they should have the break covered by another staff person to take over the one to one, and further stated residents on one on one who were asleep would still need to have staff assigned to them during that tine, and to not be left unattended.
On 2/8/21 between 11:10 AM and 12:15 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (Regional RN) acknowledged the resident to resident abuse, the lack of a one on one assigned to Resident 3 24/7 as staffing allowed, and recommendations from the 7/17/20 PASSR Level 2 were not completed.
b. The 10/5/2020 Quarterly MDS indicated the following about Resident 3:
*Cognitively impaired with a need for cues and supervision by staff.
*Several days in which she/he was unable to stay asleep or slept too much.
*Experienced delusions.
*1-3 days out of 7 in which verbal or physical behavioral symptoms were directed toward others.
*Required assistance by one staff for all personal cares.
*Received scheduled antipsychotic medication.
Review of Resident 3's current comprehensive care plan on 2/2/21 included the following recent revisions between 12/12/20 and 1/7/20:
*12/31/20 - Send the resident to the emergency department if physical aggression occurred.
*1/5/21 - Staff were to complete 15 minute checks on the resident and place her/him with a one to one "if needed."
*1/5/21 - Continue to keep staff for one to one. Staff rotation or modified sections for coverage when additional staffing is impossible.
Review of Resident 3's 12/1/20 through 1/31/21 "15 minute check sheet" revealed all dates and times to be completed by various staff members.
Review of Resident 3's 12/2020 medication administration record revealed the following:
*5.7 MG Secuado Patch (antipsychotic) for vascular dementia with behavioral disturbance. The resident received the 24 hour patch on 12/12/20 and 12/31/21.
*125 MG Depakote sprinkles (mood stabilizer) two capsules daily BID. The resident was documented to receive the medication on at 8:00 AM and 8:00 PM on 12/12/20. The resident was documented to refuse the medication at 8:00 PM on 12/30/20, and documented to receive both AM and PM doses on 12/31/20.
*500 MG Acetaminophen two tablets daily TID for pain. The resident was documented to receive all three doses on 12/12/20. The resident was documented to receive both AM doses and to refuse her/his 7:00 PM dose on 12/30/30. On 12/31/20 the resident was documented to receive all three doses.
A 12/12/20 progress note completed by Staff 32 (RN) at 8:54 PM stated she was in a resident room completing resident care when she heard yelling in the A Wing hall. Staff 32 stated she followed the noise and saw Resident 3 being wheeled back to her/his room. A CNA informed her that Resident 3 hit another resident on the back of the head. Staff 32 stated she initiated "continuous observation" and to provide Resident 3 with redirection if needed. Staff 32 indicated Resident 3 had no behaviors post the incident. The resident's physician and family were notified, and the resident was placed on alert to monitor her/his behavior. An additional progress note at the same date and time, completed by Staff 32 indicated Resident 4 had no noted injuries upon assessment and no complain of pain post incident. Staff 32 placed Resident 4 on alert to monitor for latent injury.
A facility investigation initiated 12/12/20 and signed as complete on 12/18/20 indicated Resident 3 slapped Resident 4 on the back of her/his head. The physical behavior was noted to be unprovoked. The investigation indicated Resident 3 was redirected back to her/his room and a one on one was "started."
Resident 4 did not sustain an injury and indicated that she/he felt safe despite Resident 3 currently being in the facility. The investigation included the following witness interviews and "notes."
*Staff 33 (CNA) stated Resident 3 seemed more aggressive during the day shift and had thrown things in the hallway. Resident 3 was up in A wing hall self propelling when she/he came up behind Resident 4 and smacked her/him twice on the back of the head. Staff 33 stated she directed Resident 3 back to her/his room.
*Staff 15 (CNA) stated she observed Resident 3 roll up behind Resident 4 who was seated up in her/his wheelchair in the A Wing hall. She stated Resident 3 struck Resident 4 in the back of the head before she or other staff were able to get to them.
*Resident 4 stated she/he did not know what she/he did to deserve that.
*Note by Staff 7 (Resident Care Manager) indicated Resident 4 was slapped on the back of the head twice by Resident 3 in an unprovoked incident. She stated Resident 3 had been up "roaming the halls" and was noted to be more agitated on this date. Staff 7 stated Resident 3 had a history of behaviors and aggression toward staff and other residents, and had a diagnoses of dementia with behaviors. Staff 7 stated Resident 3 would sometimes refuse her/his medication, and further stated the facility had been unsuccessful in locating a memory care facility to accept Resident 3. She further indicated family and physicians of both parties involved in the resident to resident incident were notified.
Review of Progress notes for Resident 4 dated 12/12/20 through 12/15/20 indicated alert charting was implemented and Resident 4 did not sustain any latent injury or psychosocial harm following the 12/12/20 resident to resident incident.
The 12/12/20 behavior monitoring record for Resident 3 indicated a behavior code of "2" in the afternoon hours. It is unclear what this refers to, as Resident 3's behaviors listed on the documented are not coded by number. Interventions documented to be used include "1" and "2."
Review of the 12/31/20 day, evening and night shift CNA staffing sheets for A wing revealed no documented one to one in place for Resident 3 on any shift.
A 12/31/20 facility initiated investigation at 2:15 AM indicated Resident 3 was self propelling through the A wing hall when she/he pulled Staff 24's (CNA) hair, and then punched her in the face. The physical aggression was noted to be unprovoked, and Resident 3 showed no signs of behaviors just prior to the incident. Staff 24 yelled out for help and Staff 25 (LPN) assisted and was able to remove Resident 3 from the situation. The investigation indicated the immediate action taken was to continue 15 minute checks on Resident 3 for safety. A message was sent to Resident 3's Resident Care Manager and the facility DNS. Notes were faxed to Resident 3's physician and neurologist. The "Notes" section of the investigation indicated the Care Plan for Resident 3 would be updated to send the resident to the emergency department if physical aggression occurred again.
A 12/31/20 facility initiated investigation at 5:40 AM indicated Resident 3 was self propelling through the A wing when she/he struck Resident 4, who was seated in her/his wheelchair near the nurses station of A wing, in the back of the head. The investigation indicated the incident was unprovoked. Witness interviews and "notes" included in the investigation included the following:
*Staff 26 (LPN) indicated he witness Resident 3 called Resident 4 an expletive and hit her/him in the back of the head.
*Staff 24 (CNA) stated she had to go to the break room and indicated Staff 26 was at the nurses station at the time. Staff 24 stated when she/he returned to the nurses station Staff 26 informed her Resident 2 struck Resident 4 in the shoulder.
*Five residents were interviewed and stated "they felt safe in the facility."
*A 12/31/20 note completed by Staff 7 detailed the events of the resident to resident incident as reported to her and noted Resident 3 would "continue with 15 minute checks." She further indicated social services had been actively seeking alternate placement in memory care for Resident 3. She stated the care plan would be updated to send Resident 3 to the emergency department if physical aggression occurred again.
*A 1/4/21 note completed by Staff 2 (DNS) indicated a PASSR Level 2 was completed in the last 6 months and "medication recommendations were reviewed and followed." She further indicated social services staff was looking into "requirements/steps needed for placement at an [enhanced care facility] or other setting that would better meet the [Resident 3's] needs.
Review of Resident 4's progress notes for 12/31/20 through 1/3/21 indicated alert charting was implemented and Resident 4 did not sustain any latent injury or psychosocial harm following the 12/31/20 resident to resident incident.
Review of Resident 3's 12/31/20 behavior monitoring record had no documented behaviors for the resident.
Review of the 1/1/21 through 1/6/21 day, evening and night shift CNA staffing sheets for A wing revealed the following:
*1 occasion when a CNA staff was noted to be a one on one, and to help with "lights" and "rounds" with no indication what room a one to one was assigned for.
*2 occasions when a CNA staff was noted to be a one to one for Resident 3 on 2nd and 5th of the month.
*2 occasions when a CNA staff was noted to be a one to one for Resident 3 and noted to "help out" a fellow CNA with their assigned rooms on the 4th and 6th of the month.
*3 occasions when a CNA staff was noted to be assigned as a one to one, with no indication what room required the one to one on the 3rd, 4th and 6th of the month.
*None of the dates included a fellow CNA or staff person that would cover a CNA assigned to a one to one during their breaks.
On 2/2/21 between 2:15 and 2:30 PM Staff 2 (DNS) was made aware of the 2/2/21 interview with Staff 4. Staff 2 was also unaware of why Witness 2 was listed as Resident 3's resident repetitive and further indicated that Resident 3's spouse was not reliable and was often difficult to work with. Staff 2 acknowledged the suggested recommendations in the 7/17/20 PASSR Level 2 were to help ensure all measures had been taken by the facility to ensure the quality of life and safety of Resident 3, fellow residents and staff. Staff 2 was given an opportunity to provide documentation regarding the potential that Witness 2 was contacted specifically related to the potential to attempt to gain legal guardianship, and to indicate if Witness 4 had been contacted by the facility as per the PASSR Level 2 recommendations. Staff 2 was unable to provide the documentation requested.
On 2/3/21 at 11:42 AM Witness 4 was asked if he had been contacted by the facility following Resident 3's 7/17/20 PASSR Level 2 being completed. Witness 4 stated he had not been contacted by the facility regarding the recommendation until 2/2/21.
On 2/8/21 at 1:05 AM Staff 24 (CNA) stated she was one of three CNAs working in the facility on the night shift of 12/31/20. Staff 24 stated she was in the A-wing hall in the 2:00 AM hour watching Resident 4 as a one to one, due to her/his high risk of falling. Staff 24 stated Resident 3 was self propelling down A-hall and once the resident began to pass by, she/he grabbed Staff 24 by the hair and then punched her/him in the face. Staff 24 yelled out for help and Staff 25 (LPN) assisted in redirecting Resident 3 back to her/his room. Staff 24 stated Staff 25 then assisted Resident 3 back into bed, and when she turned around Resident 3 punched Staff 25 in the stomach. Staff 24 indicated a few hours later Resident 3 was back up and self propelling in the A-wing near the nurses station. Resident 4 was also seated in her/his wheelchair near the nurses station. Staff 24 stated she stepped away to the break room and believed Staff 26 (RN) was seated at the nurses station at the time. Staff 24 stated there were not enough CNA staff working on the night of 12/31/20 to provide the one on one resident care needed. Staff 24 confirmed Resident 3 was not assigned a one on one following her/his physical aggression towards staff, prior to her/his physical aggression toward Resident 4.
On 2/8/21 at 8:55 AM Staff 25 confirmed Resident 3 was not placed on a one on one on the night shift of 12/31/20 after she/he was physically aggressive with her and with Staff 24 in the early morning hours. Staff 25 stated Resident 3 was typically "pretty active at night." Staff 25 stated Resident 3 slept for awhile, and then got back and was self propelling in the A wing hall around five AM. Staff 25 stated she believed there may have been up to three residents in the building who needed one on one staff for various reasons during the night shift, and confirmed Resident 4 was on a one on one the night of 12/31/20 due to being a fall risk.
On 2/9/21 at 10:18 AM Staff 26 (LPN) stated he worked the night shift of 12/31/20 on the B wing hall. Staff 26 stated he was not seated at the nurses station at the time Resident 3 hit Resident 4. Staff 26 stated he was coming around the corner when he saw Resident 3 and Resident 4 near the A wing nurses station and by the time it took to reach the residents, Resident 3 had struck Resident 4 in the back of the head. Staff 26 stated there were no staff present with Resident 3 and Resident 4 a the time of the incident.
On 2/8/21 between 11:10 AM and 12:15 PM Staff 1 (Administrator) Staff 2 (DNS) and Staff 3 (Regional RN) acknowledged the resident to resident abuse.
2. Resident 1 admitted to the facility in 8/2020 with diagnoses including altered mental status, anxiety and dementia with behaviors.
A 9/19/20 facility initiated investigation alleges Resident 1 was verbally abused by Resident 2 in their shared room on A hall during the afternoon hours of 9/19/20.
A 9/19/20 witness statement by Staff 6 indicated she was in the A hall shower room about to bathe a resident when she heard "loud banging." The witness further stated Resident 1 was banging on the emergency exit door at the end of A hall. Staff 6 (CNA) stated she saw Staff 21 (Former RN) and Staff 3 (CNA) "assisting the resident."
On 9/22/20 the summary of the investigation was completed by Staff 17 (RCM) in the "Notes" section of the document. The summary contradicts the location of the resident during the time she/he was banging on a window with a foot pedal, based on various witness interviews, and indicates the behaviors all occurred within Resident 1 and Resident 2's shared room. The investigation does not indicate when Resident 1 was last toileted or received cares prior to the incident. There is no clear timeline of the events, and a root cause for the incident was not established. The investigation further failed to rule out abuse and neglect.
In an interview on 2/3/21 at 12:25 PM Staff 6 (CNA) stated she was in the A shower hall when she heard loud noise coming from the hall. She stated Resident 1 was banging at the door at the end of A hall.
In an interview on 2/3/21 at 1:16 PM Staff 3 (CNA) stated Resident 1 had a been in the A wing using the foot pedal of a nearby empty wheelchair to bang on the fire door at the end of A hall, yelling about a fire. Staff 3 stated she was able to redirect Resident 1 and placed her/him back in the room shared with Resident 2. She stated she placed Resident 1 who was in her/his wheelchair at the end of her/his bed. She was unable to recall if Resident 1 still displayed agitation at the time she left the room. Staff 3 stated she left Resident 1 alone in the room with Resident 2, and within about ten minutes of the incident Resident 1 began to grab Resident 2's property and become verbally abusive toward Resident 2.
On 2/1/21 at 12:30 PM Resident 2 stated she/he shared a room with Resident 1 and on 9/19/20 she/he was in bed at the time she/he was verbally abused by Resident 1. Resident 2 stated Resident 1 self propelled her/his wheelchair towards her/him, took one of her/his boots and started slamming it against the window in the room. Resident 2 stated she/he then hit her/his call light and yelled out for help from staff, and at that point Resident 1 stated "I'm going to kill you or stab you." Resident 2 stated he felt unsafe, but staff arrived quickly and were able to separate the two residents after about ten minutes. Once staff arrived, Resident 2 stated he felt safe. Resident 2 further stated upon being placed in a new room she/he no longer felt fearful, and did not feel any residual fear or emotional trauma following the event.
On 2/3/21 at 1:16 PM Staff 3 (CNA) stated Resident 1 had a been in the hallway using the foot pedal of a nearby empty wheelchair to bang on the fire door at the end of A hall, yelling about a fire. Staff 3 stated she was able to redirect Resident 1 and placed her/him back in the room shared with Resident 2. She states she placed Resident 1 in her/his wheelchair at the end of her/his bed. She was unable to indicate if Resident 1 still displayed agitation at the time she left the room. Staff 3 stated she left Resident 1 alone in the room with Resident 2, and within about ten minutes Resident 1 grabbled Resident 2's property and became verbally abusive toward Resident 2.
On 2/8/21 between 11:10 AM and 12:15 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (Regional RN) acknowledged the resident to resident verbal abuse.
Residents 1 and 2 have discharged from the facility. Residents 4, 5 and 6 still reside at the facility without signs of fear or abuse. Resident 3s PASRR II was reviewed with all recommendations initiated and ongoing. Resident 3 has dedicated staff, providing 1:1 supervision, per facility policy. Current residents charts have been reviewed to ensure appropriate interventions are in place and providers recommendations have been followed.Management has been instructed on initiating PASRR II and provider recommendations. Staff educated on Abuse & Neglect, 1:1 policy and following interventions as implemented. Nursing staff have been educated to include specific behavior that occurred when completing behavior monitoring documentation. DNS or designee to audit 5 charts of behavioral residents weekly x 4 weeks then monthly x 2 months to ensure mental health provider recommendations have been followed, behavioral interventions are in place and behavior charting is comprehensive. Audit results will be forwarded to the QAPI committee to review trends until substantial compliance is achieved.
Based on interview and record review it was determined the facility failed to ensure an allegation of resident to resident verbal abuse be reported to the state agency with 24 hours for 1 of 6 sampled residents (Resident 2). This placed residents at risk for continued abuse.
The facility's policy for Abuse, updated 7/2020 included "...all suspected, alleged, or actual cases of resident abuse, including injuries of unknown origin, shall be thoroughly and completely investigated and reported according to State and Federal regulations.
Resident 2 admitted to the facility with a local infection of the skin and subcutaneous tissue. The resident was cognitively intact and able to make her/his needs known.
A facility investigation dated 9/19/20 indicated Resident 2 alleged she/he was verbally abused by Resident 1.
A facility reported incident was received by state agency on 12/22/20, three days following an allegation of resident to resident verbal abuse.
On 1/26/21 Staff 2 (DNS) acknowledged the incident was not reported to the State Survey Agency within 24 hours.
Resident 2 has discharged from the facility. Abuse or neglect incidents in the last two weeks have been reviewed to ensure they were reported within the specified timeframe. Staff educated on Abuse & Neglect, reportable events and time frames to report. DNS or designee will audit 5 investigations for timeliness in reporting weekly x 4 weeks then monthly x 2 months. Audit results will be forwarded to the QAPI committee to review trends until substantial compliance is achieved.
Based on interview and record review it was determined the facility failed to complete thorough investigations of verbal and physical abuse for 2 of 6 sampled residents (#s 1 and 3) reviewed for allegations of abuse. This placed residents at risk for continued abuse. Findings include:
The undated facility document titled "Accident/Incident Investigations - Developing a Root Cause Analysis" was obtained on 2/2/21 by Staff 2 (DNS). The document included the following: "...a guide of the root cause analysis for the individual resident accident/incident. Looking for the underlying cause is vital in preventing reoccurrence. Ruling out abuse and neglect is completed once all data is gathered and analyzed. The document provided the following criteria for developing a root cause analysis for a facility investigation.
*Step one: Obtain the resident's statement, regardless of cognitive status. Document the resident's response.
*Step two: Staff interviews must be completed.
*When was care last provided, when was the resident last toileted, were all assistive devices in place?
*Step four: Review the entire care plan to determine if all interventions were followed.
*Step Five: Evaluate and document any history that is pertinent to the investigation.
*Step eight: Develop a timeline of the event. (Just a reminder that when developing the timeline, it might open up a need for more interviews of staff to match the timeline.)
*Step nine: Root cause analysis is formulated, ask the 5 whys, (Just a reminder with the root cause that it should be a summary of all the data and paint a picture of the resident, their day to day routine and risk) abuse and neglect rule out out.
Step ten: care plan reviewed and revised to with interventions to prevent/mitigate reoccurrence.
The facility's 7/2020 Abuse Prevention Policy and Procedure included: "It is the policy of this facility that all suspected, alleged, or actual cases of resident abuse... shall be thoroughly and completely investigated and reported according to the State and Federal regulations.
1. Resident 3 admitted to the facility in 6/2019 following a stroke, and was later diagnosed with dementia with behaviors in 12/2019.
a. A 6/20/20 facility initiated investigation that alleged Resident 5 and Resident 6 were in their shared room, when Resident 3 entered the room and was witnessed to be verbally and physically aggressive.
A 6/20/20 facility investigation witness interview with Staff 27 (Former LPN) indicated Resident 3 was found roughly two hours prior to the alleged investigated incident, to be in the shared room of Residents 5 and 6 and to be cursing at them. There was no other indication in the investigation to indicate the investigated allegation was the second possible attempt of Resident 3 to be verbally aggressive toward Resident 5 and 6.
A witness interview in the 6/20/20 facility investigation interview with Resident 5 indicated she/he was hit in the nose with a mini flashlight thrown at her by Resident 3.
A 6/22/20 "note" included in the investigation by Staff 17 (Resident Care Manager) indicated Resident 5 was hit in the "cheek area." This was inconsistent with Resident 5's interview, and it was not clarified by further interview with Resident 5 to ensure the incident was documented accurately.
The 6/20/20 facility initiated investigation did not indicate when care was last provided for Resident 3. The investigation made no indication if the resident's current care plan was reviewed to ensure current interventions related to her/his behaviors and wandering were in place at the time of the incident. The investigation further did not include a root cause analysis that encompassed the varied resident and witness interviews regarding the timeline of events, which included an alleged incident earlier in the day in which Resident 1 is alleged to be verbally abusive to Residents 5 and 6. The investigation further failed to ensure accurate information related to the location of Resident 5's non-injury physical abuse from Resident 3. The investigation ruled out abuse and neglect, despite witnessed verbal and physical abuse by facility staff, of Residents 5 and 6.
On 2/8/20 between 11:10 AM and 12:15 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (Regional RN) acknowledged the investigation was not thorough. Staff 2 (DNS) was unable to indicate how she was able to rule out abuse and neglect.
b. A 12/12/20 facility initiated investigation indicated Resident 4 was witnessed by staff near the A hall nurses station to be slapped in the back of the head by Resident 3.
The 12/12/20 facility investigation did not indicate when either Resident 3 or 4 had last received cares. The investigation did not indicate if staff reviewed Resident 3 and Resident 4's care plans to ensure all care planned interventions were in place for both residents at the time of the incident. There was no root cause analysis in the investigation, and he facility investigation did not rule out abuse or neglect.
On 2/8/21 at 11:10 AM and 12:15 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (Regional RN) acknowledged the investigation was not thorough and did not rule out abuse or neglect.
c. A 12/31/20 facility initiated investigation indicated Resident 3 physically attacked Staff 24 (CNA) and Staff 25 (LPN). The investigation indicates the physical aggression occurred at 2:15 AM.
A 12/31/20 facility initiated investigation indicated Resident 4 was witnessed by staff near the A hall nurses station to be slapped in the back of her/his head by Resident 3. The incident was documented to occur at 5:40 AM.
The 12/31/20 investigation initiated at 5:40 AM did not indicate if care planned interventions were in place for both Resident 3 and Resident 4 at the time of the incident. The investigation did not refer to the prior physical abuse inflicted on facility staff by Resident 3 in the earlier morning hours of 12/31/20, and therefore did not evaluate and document a historical event that was pertinent to the investigation. There was no timeline of events included in the investigation, nor did the investigation indicate when cares were last provided to both Residents 3 and 4. No root cause analysis was developed, and abuse and neglect were not ruled out.
On 2/8/21 at 11:30 AM and 12:10 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (Regional RN) acknowledged the investigation was not thorough and did not rule out abuse or neglect.
2. Resident 1 admitted to the facility in 8/2020 with diagnoses including kidney failure, altered mental status and anxiety.
The 8/14/20 Admission MDS indicated Resident 2 was alert and oriented, and required extensive physical assist by two staff for transfers in and out of her/his bed.
A 9/19/20 facility initiated investigation alleges Resident 2 was verbally abused by Resident 1 in their shared room on A hall during the afternoon hours of 9/19/20. The investigation did not include what time the alleged incident occurred.
A 9/19/20 witness statement by Staff 6 (CNA) indicated she was in the A wing hall shower room about to bathe a resident when she heard "loud banging." The witness further stated Resident 1 was banging on the emergency exit door. Staff 6 stated she saw Staff 21 (Former RN) and Staff 3 (CNA) "assisting the resident." The witness statement did not indicate an estimate of the time she witnessed Resident 1 in the hallway.
A 9/19/20 Witness statement by Staff 3 indicated Resident 1 was "banging on a glass window with a wheelchair footrest and trying to escape. A little after this the resident wheeled her/himself up to her/his roommate's TV and started pulling on her/his TV plugs acting confused and aggressive. I had checked on her/him 10 minutes prior." The witness statement did not indicate a timeline of the events, or the location of Resident 1 when she/he was "banging on the glass window." The witness statement further did not indicate if Staff 3 herself or Staff 21 (Former RN) was involved in assisting Resident 1 in the hallway, as the witness statement provided on 9/19/20 by Staff 6 (CNA) indicated.
A 9/19/20 witness statement by Staff 21 (CNA) stated she "watched [her/him] bang leg rest against back window and say there was a fire in the hall and throwing stuff around his room and cursing at staff in the hall." The witness statement does not indicate a timeline of the incident or the location of the resident at the time of the various behaviors.
A 9/19/20 witness statement by Staff 22 (CNA) stated she/he was "in another room and heard [a] banging noise and he was hitting [the] window with foot pedal trying to break it to get away from the fire that wasn't real." The witness statement does not indicate a timeline of the incident or where she suspected the location of the resident to be when she heard the noise.
On 2/3/21 at 12:25 PM Staff 6 (CNA) stated she was in the A shower hall when she heard loud noise coming from the hall. She stated Resident 1 was banging at the door at the end of A hall.
On 2/3/21 at 12:39 PM Staff 17(Resident Care Manager) stated she did not work the day of the incident, which occurred on a Saturday. She stated Staff 7 (Resident Care Manager) was working on the day of the incident and had completed most of the investigation but that she had "wrapped up the investigation." Staff 17 further stated on the day of the incident Resident 1 believed there was a fire in the hall and "self propelled" back to her/his room prior to being verbally aggressive with Resident 2.
On 2/3/21 at 1:16 PM Staff 3 (CNA) stated Resident 1 had a been in the hallway using the foot pedal of a nearby empty wheelchair to bang on the fire door at the end of A hall, yelling about a fire. Staff 3 stated she was able to redirect Resident 1 and placed her/him back in the room shared with Resident 2. She states she placed Resident 1 in her/his wheelchair at the end of her/his bed. She was unable to indicate if Resident 1 still displayed agitation at the time she left the room. Staff 3 stated she left Resident 1 alone in the room with Resident 2, and within about ten minutes the incident of Resident 1 became verbally abusive to Resident 2.
On 9/22/20 the summary of the investigation was completed by Staff 17 (Resident Care Manager ) in the "Notes" section of the document. The summary contradicts the location of the resident during the time she/he was banging on a window with a foot pedal, based on various witness interviews, and indicates the behaviors all occurred within Resident 1 and Resident 2's shared room. The investigation does not indicate when Resident 1 was last toileted or received cares prior to the incident. There is no clear timeline of the events, and a root cause for the incident was not established. The investigation further failed to rule out abuse and neglect.
On 2/8/21 between 11:10 AM and 12:15 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (Regional RN) acknowledged the investigation was not thorough and failed to rule out abuse.
Current incidents audited for comprehensive investigation elements.Licensed nursing staff educated on the common elements that must be included in the initial investigation. Nurse managers instructed on the elements that must be included in an abuse investigation to provide a comprehensive summary of events. (Elements: root cause statement, care plan statement, abuse/neglect statement and basic timeline of events) DNS or designee will audit 5 investigations for presence of basic elements weekly x 4 weeks, then monthly x 2 months. Audit results will be forwarded to the QAPI committee to review trends until substantial compliance is achieved.
The findings of the health complaint survey (Intake #26488) conducted 1/26/21 through 2/9/21 are documented in this report. The survey was conducted to determine compliance with OAR 411 Divisions 85 through 89. For additional information refer to the Form CMS 2567 dated 2//9/21.
The sample was comprised of 4 current residents and 2 closed records. The facility had a census of 52 residents.
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
BIMS: Brief Interview for Mental Status
CAA: Care Area Assessment
CBG: capillary blood glucose or
blood sugar
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
CPR: Cardiopulmonary Resuscitation
DNS: Director of Nursing Services
F: Fahrenheit
FRI: Facility Reported Incident
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MAR: Medication Administration
Record
mcg: microgram
MDS: Minimum Data Set
mg: milligram
ml: milliliters
O2 sats: oxygen saturation in the
blood
OT: Occupational Therapist
PCP: Primary Care Physician
PO: by mouth, orally
PRN: as needed
PT: Physical Therapist
RA: Restorative Aide
RAI: Resident Assessment
Instrument
RD: Registered Dietician
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care
Manager
SLP: Speech Language
Pathologist
TAR: Treatment Administration
Record
tid: three times a day
UA: Urinary Analysis
UTI: urinary tract infection
The findings of the revisit complaint (Intake # 26488) health survey conducted 3/30/21 are documented in this report. The facility was found to be in substantial compliance with OAR 411 divisions 85 through 89.
OAR 411-085-0360 Abuse
Refer to F600, F609 and F610
