Based on interview and record review it was determined the facility failed to ensure care planned interventions were in place to prevent elopement for 1 of 3 sampled residents (#3) reviewed for accidents. This placed residents at risk for related injuries. Findings include:
Review of the facility Elopement & Wandering policy and procedures, revised 2007, indicated the residents considered a high risk from the wander/elopement risk evaluation should have upgraded interventions developed and implemented. Residents identified as high risk for elopement shall have an Elopement Identification Form implemented and placed in the Elopement Binder, which was to include a current photo and physical description of the resident. The policy and procedure revealed "This facility utilizes a wanderguard system to alert staff that a resident is nearing an exit or has exited the facility." The wanderguard/elopement risk care plan will be updated.
Resident 3 admitted to the facility on 12/17/19 with diagnoses including Wernicke's encephalopathy (neurological condition), major depression and alcohol dependence with withdrawal delirium (disturbance in mental abilities).
Record review of the 12/17/19 Wander/Elopement Risk Evaluation revealed Resident 3 was considered a high risk for elopement. The evaluation indicated Resident 3 had the following:
- currently wanders or had a history of wandering;
- cognitive impairment;
- recent history of alcohol/substance abuse;
- made previous attempts to elope;
- impaired decision-making skills.
Resident 3's Baseline care plan initiated on 12/17/19, revealed Resident 3 was not an elopement risk under Safety Risks section.
Review of the 12/24/19 Admission MDS indicated Resident 3 wandered one to three days during the assessment look back period. Resident 3 was assessed to not walk in room or corridor and only able to stabilize with staff assistance while walking and used a wheelchair for mobility.
Resident 3's care plan for risk of elopement was developed and initiated on 1/6/20. Interventions included the following:
- to encourage resident to stay in common areas of building for observation if needed;
- provide for safe ambulation with comfortable and well-fitting clothes, shoes with non-skid soles and foot support, and any necessary walking aides;
- resident had left facility AMA (against medical advice) once before;
- resident was easily confused and easily redirectable;
- wander assessment to be completed quarterly and PRN to monitor for ongoing need;
- when wandering, redirect resident to another activity.
Record review of progress notes revealed the facility staff recognized on 1/14/20 at 12:20 AM, Resident 3 was missing from the facility. The facility notified the police of Resident 3 missing from the facility on 1/14/20 at 12:30 AM. The police notified the facility Resident 3 was arrested for trespassing at a women's shelter and was released from custody in downtown Portland. Resident 3 was later found and returned to the facility without harm or injury.
In an interview on 2/4/21 at 2:45 PM, Staff 1 (Administrator) confirmed Resident 3 had discharged from the facility in 3/2020. Staff 3 acknowledged he was the most knowledgeable staff of Resident 3 and the elopement, as other staff with knowledge of the elopement no longer worked at the facility. Staff 1 acknowledged Resident 3 was identified as a high risk for elopement and no care plan for elopement until 1/6/20 when he wrote the plan. Staff 1 confirmed, Resident 3 had no care plan interventions in place for potential elopement from 12/17/19 to 1/6/20. Staff 1 acknowledged Resident 3's care plan interventions listed from 1/6/20 to 1/14/20, at the time of the elopement, were not resident specific for Resident 3. Staff 1 acknowledged he expected care plan interventions written specific to the resident and Resident 3's interventions were not resident centered to prevent elopement.
Based on observation, interview and record review it was determined the facility failed to assess and implement interventions related to weight loss for 1 of 3 sampled residents (#1) reviewed for weight loss. This placed residents at risk for continued weight loss. Findings include:
Resident 1 was admitted to the facility in 4/2019 with diagnoses including Type 2 Diabetes Mellitus.
On 2/3/21 at 10:11 AM, Resident 1 was observed in her/his bed, awake and alert and presented oriented to current events, date and time. Resident 1 stated she/he recently lost about 32 pounds, she/he was still losing weight and nobody at the facility talked to her/him regarding her/his weight loss. Resident 1 stated she/he was weighed "two days ago."
Review of Resident 1's medical record revealed an 11/30/20 Physician Order: "Weight weekly x 4 weeks or until stable, then monthly thereafter."
Resident 1's 11/2020 and 12/2020 MAR/TAR did not include the weekly weights order or documentation related to obtaining Resident 1's weights as ordered.
Resident 1's Weights Report indicated the following weights:
- 10/1/20: 260.4 pounds
- 12/14/20 228.0 pounds
No other weights were documented in Resident 1's medical records.
Resident 1's 11/19/20 Care Conference revealed "no medical concerns at this time." The nutrition portion of the Care Conference indicated Resident 1' s current weight of 260.4 pounds.
Resident 1's medical record revealed no nutritional assessment, no progress notes, no dietary assessment and no interventions related to her/his 32.4 pound weight loss over 75 days. Records revealed no nutritional assessment was completed for Resident 1 since 5/2020, which was over seven months.
On 2/3/21 at 1:49 PM, Staff 10 (LPN Resident Care Manager) stated Resident 1's weight loss should have triggered a warning and Staff 14 (RD) and Staff 2 (DNS) should have been notified.
On 2/4/21 at 8:54 AM, a phone call was made to Staff 14 to obtain details. Staff 14 did not return the call by the survey exit date and no additional information was provided.
On 2/4/21 at 12:05 PM, Staff 2 stated the physician order was missed and Resident 1 did not get weighed weekly as ordered. Staff 2 acknowledged no nutritional assessment was completed after Resident 1's significant weight loss and confirmed no nutritional assessment was completed in over seven months. Staff 2 stated the facility protocol for a significant weight loss included following physician orders to obtain weights, obtain recommendations from the dietician and physician, assess the resident for food likes and dislikes, implement interventions and encourage supplements. Staff 1 (Administrator) and Staff 2 acknowledged the Resident 1's significant weight loss was not assessed and interventions were not implemented.
4. On 2/4/21 at 10:25 AM, a request for a copy of the facilities current Influenza Policy and Pneumococcal Policy was made to Staff 2 (DNS).
On 2/4/21 at 11:07 AM, the facility's current Influenza Policy was received via email from Staff 2.
Review of the facility's Influenza Vaccine Policy revealed the revision date 11/2012.
On 2/4/21 at 11:08 AM, the facility's current Pneumococcal Policy was received via email from Staff 2.
Review of the facility's Pnuemococcal Vaccine Policy revealed the revision date 10/2014.
No other information was provided by the facility.
, Based on observation, interview and record review it was determined facility failed to follow appropriate infection control practices in a manner to reduce and/or prevent the potential contamination and spread of the COVID-19 virus in 1 of 1 laundry services, 1 of 2 units and annually revise immunization policy and procedures reviewed for infection control. This placed residents at risk for cross contamination and possible exposure to infectious agents. Findings include:
1. Review of CDC Preparing for COVID-19 in Nursing Homes, dated 6/25/20, under Environmental Cleaning and Disinfection showed "Develop a schedule for regular cleaning and disinfection of shared equipment, frequently touched surfaces in resident rooms and common areas; Ensure EPA-registered, hospital-grade disinfectants are available to allow for frequent cleaning of high-touch surfaces and shared resident care equipment ... Ensure HCP (healthcare personnel) are appropriately trained on its use."
On 2/1/21 at 1:00 PM, Staff 8 (Housekeeping/Laundry) was observed to wipe the hall railings and doorknobs with a cloth rag. Staff 8 was observed to lightly spray the rag with Lysol Disinfectant, then wipe the high touch surfaces. Staff 8 was observed to wipe the doorknob of an office door across from the nursing station with the rag. The surveyor touched the same doorknob less than 15 seconds later and the doorknob was dry to touch.
Review on 2/1/21 of the Lysol Disinfectant, EPA Reg no. 777-66 - EPA est no. 777-MO-001(S), spray bottle instructed user "To Disinfect: Leave 2 minutes before wiping..."
On 2/3/21 at 9:41 AM, Staff 7 (Housekeeping) was observed to spray the outside plastic table and plastic chairs on the dining room patio with the Lysol Disinfectant and immediately wipe with a rag.
On 2/3/21 at 10:21 AM, Staff 7 was observed in the dining room to spray the five dining room tables, a bedside table and the sliding door handle with a blue liquid in a spray bottle. Staff 7 immediately wiped with a cloth rag after spraying the blue liquid.
On 2/3/21 at 10:27 AM, Staff 7 was observed to start at the front reception office to wipe the high touch areas including the hallway railings, doorknobs, time clock and nursing station. Staff 7 used multiple Super Sani-Cloth Germicidal Disposable Wipes. Surveyor touched the hand railing surface immediately behind Staff 7 and the surface was dry to touch. Staff 7 completed the West and then the East halls, nursing station and back to the front office at 10:32 AM, which was a five minute completion time.
On 2/3/21 at 10:35 AM, Staff 1 (Administrator) stated the Super Sani-Cloth Germicidal Disposable Wipes were always used when cleaning the high touch areas and no other disinfectants were to be used. Staff 1 stated he expected the contact time, which was a wet surface, to be two minutes for these wipes.
On 2/3/21 at 1:52 PM, Staff 7 stated the blue spray was for a window glass cleaner. Staff 7 reported they were only to use the Lysol Disinfectant spray outside or in resident bathrooms. Staff 7 demonstrated how he filled the blue spray bottle from a large container located in the housekeeping storage room labeled Sparkle. Staff 7 confirmed he should not have used the Sparkle cleaner on the tables and door handle for disinfectant cleaning.
On 2/5/21 at 12:40 PM, Staff 3 (DNS/Infection Control Preventionist) stated she expected staff to use the Lysol Disinfectant outside and in resident bathrooms and to spray the surface, let it sit for two minutes, then wipe. Staff 3 acknowledged the cleaning of high touch areas should remain wet for the recommended contact time to disinfect.
2. Centers for Disease Control "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During Coronavirus Disease 2019 (COVID-19) Pandemic" revised 7/15/20 instructed facilities to ensure environmental cleaning and disinfection procedures were followed consistently and correctly.
On 2/1/21 at 1:26 PM, two surveyors and one staff person entered the facility. Staff 9 (CNA) began the screening process. Staff 9 was observed to pick up a thermometer from a basket on the staff/visitor screening table and take all three temperatures with no disinfection before or between people. Staff 9 placed the thermometer back into the basket and left the thermometer in the basket with no disinfection.
On 2/3/21 at 9:40 AM, Staff 4 (Activity Director) began the screening process upon two surveyors entry to the facility. Staff 4 was observed to pick up a thermometer from a basket on the staff/visitor screening table and take the temperatures of the two surveyors with no disinfection before or between people. Staff 4 placed the thermometer back into the basket and left the thermometer in the basket with no disinfection.
On 2/5/21 at 12:23 PM, Staff 1 (Administrator) confirmed staff were expected to disinfect the thermometer between people and before leaving in the basket after touching.
3. On 2/1/21 at 1:30 PM, observation was made in the laundry room of a standing fan blowing towards clean linen and clothing. The fan was coated with dust and hair like strands blowing from the blade guard.
On 2/3/21 at 11:16 AM, Staff 8 (Housekeeping /Laundry) acknowledged the fan was blowing due to it was hot in the room. Staff 8 reported the COVID-19 positive unit dirty laundry passed through the clean linen side in front of the blowing fan. Staff 8 reported the washing machines were cleaned one time a day at the end of the shift. Staff 8 confirmed she did not clean the washing machine between loads, including the COVID-19 positive laundry.
On 2/4/21 at 11:31 AM, observation was made in the laundry room of a standing fan blowing towards clean linen and clothing. The fan was coated with dust and hair like strands blowing from the blade guard.
On 2/4/21 at 11:50 AM, Staff 2 (Administrator in Training) confirmed the fan was blowing in the laundry room and direct towards the clean linen and clothing.
On 2/5/21 at 12:23 PM, Staff 1 (Administrator) confirmed the fan should not be in the laundry room.
On 2/5/21 at 12:40 PM, Staff 3 (DNS/Infection Control Preventionist) acknowledged the fan should not be in the laundry room, the washing machines were expected to be disinfected between loads and the COVID-19 positive dirty laundry should not pass through the clean linen area.
Based on interview and record review it was determined the facility failed to ensure immunizations were provided for 2 of 5 sampled residents (#s 10 and 11) reviewed for immunizations. This placed residents at risk of communicable infections. Findings include:
1. Resident 10 was admitted to the facility on 12/2/20 with diagnoses which included heart and kidney failure.
The facility's Influenza Vaccine Policy revised 11/2012 "Revealed residents admitted between October 1st and March 31st shall be offered the vaccine within the first week of admission to the facility".
A 12/2/20 physician order revealed "May offer flu vaccine annually between Oct 1 and March 31".
A 12/2/20 progress note revealed facility staff would verify if Resident 10 received the influenza immunization from a previous facility she/he resided. A review of progress notes from 12/2/20 through 2/4/21 revealed no evidence in the resident's health record which indicated follow up was completed, and if the resident was offered and administered the immunization.
The 12/2020 and 1/2021 MAR had no evidence Resident 10 was offered or received the influenza immunization.
On 2/4/21 at 10:25 AM Staff 3, DNS indicated she could not find any follow up information regarding the resident's immunization status from the previous facility. She confirmed the resident did not receive the immunization in this current facility. Staff 3 stated she spoke to the resident, who consented to the immunization, and the resident's physician who authorized the immunization to be given. Staff 3 stated the influenza immunization would be given to the resident on this date.
A 2/4/21 10:54 AM progress note revealed the facility received consent from the resident for the influenza immunization, her/his physician was notified, and the immunization was provided to the resident on 2/4/21.
2. Resident 11 was admitted to the facility on 11/25/20 with diagnoses which included acute and chronic respiratory failure. She/he was discharged from the facility on 1/26/21.
The facility's Pneumococcal Vaccine Policy revised 10/2014 revealed residents would be offered pneumococcal vaccines and they would be administered per the facility's physician approved pneumococcal vaccination protocol.
An 11/25/20 physician order revealed "May offer pneumococcal vaccine upon admission and q 5 (every 5) years if deemed appropriate by MD".
A review of the resident's electronic health record found a Consent Form For Pneumococcal Vaccine document signed by the resident but not dated. The undated document was scanned into the facility's electronic health record system on 11/26/20.
An 11/25/20 progress note revealed Resident 11 consented for the pneumonia immunization.
An 11/29/20 progress note revealed "Prevnar 13 Suspension Inject 1 dose intramuscularly one time only for immunization for 1 day medication not here, rescheduled".
An 11/30/20 progress note revealed "Prevnar 13 Suspension Inject 1 dose intramuscularly for 2 days record administration under immunization tab unavailable. Awaiting delivery from pharmacy. Reordered".
A review of progress notes from 11/25/20 through 1/26/21 revealed no evidence Resident 11 was administered the pneumococcal immunization.
On 2/4/21 at 10:26 AM Staff 3, DNS stated she checked the pneumonia vaccines in the facility fridge and Resident 11's vaccine was still in there. She confirmed Resident 11 did not receive the pneumonia immunization and Resident 11 had since discharged from the facility.
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OAR 411-086-0110 Quality of Care: Nursing Services: Resident Care
Refer to F689
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OAR 411-086-0140 Quality of Care: Nursing Services: Problem Resolution & Preventive Care
Refer to F692
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OAR 411-086-0330 Infection Control: Infection Control and Universal Precautions
Refer to F880
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OAR 411-086-0140 Infection Control: Nursing Services: Problem Resolution & Preventive Care
Refer to F883
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