A COVID-19 Focused Emergency Preparedness Survey was conducted by the Oregon State Survey Agency from 1/26/21 to 2/8/21. The facility was found to be in compliance with 42 CFR 483.73 related to E-0024 (b) (6).
Total residents: 51
A COVID-19 Focused Infection Control Survey and health complaint (intake #s 24766, 25603 and 25744) was conducted by the Oregon State Survey Agency on 1/26/21 to 2/8/21.
The survey sample, based on a resident census of 51, included 5 sampled residents.
On 2/4/21 at 11:30 AM the facility's Administrator and DNS were notified of an Immediate Jeopardy (IJ) determination for 42 CFR §483.25 (d) (F689) related to Resident 2 required 1:1 supervision with eating and staff did not provide supervision for the resident. Based on observation, interview and record review it was determined the facility failed to provide supervision for swallowing safety for Resident 2 who had a physician order for 1:1 supervision with meals and had a dementia diagnosis. A pink sign hung above Resident 2's bed indicated the resident required 1:1 supervision and was on aspiration precautions. Resident 2 was observed to receive assistance with the meal tray at breakfast by Staff 17 (Agency CNA). Continuous observations of the resident were completed by this surveyor on 2/3/21. At 8:08 AM Staff 17 set a meal tray in front of the resident then left the room at 8:10 AM, the resident was alone with the meal tray in her/his reach until 8:11 AM when Staff 17 returned. Staff 17 left the room at 8:13 AM, the resident was alone with the meal tray in her/his reach. Staff 2 (DNS) was asked by this surveyor to enter Resident 2's room. Staff 2 entered the room at 8:15 AM and stated she was unsure if Resident 2 should be left unattended with a meal tray and removed the meal tray. Staff 17 returned to the room at 8:18 AM and confirmed Resident 2 should not have been left alone with the meal tray on the two identified occasions.
On 2/4/21 Staff 1 was notified the immediacy was removed based on onsite verification that the IJ removal plan was implemented. Following the removal of the immediacy, noncompliance remained at a scope of "E" (pattern, no actual harm with potential for more than minimal harm).
The facility was found to be providing Substandard Quality of Care in the area of:
CFR 483.25 Quality of Care
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 Dietitian
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care Manager
SA: State Agency
SLP: Speech Language Pathologist
TAR: Treatment Administration Record
tid: three times a day
UA: Urinary Analysis
UTI: Urinary Tract Infection
The findings of the complaint (Intake #s 24766, 25603 and 25744) health revisit survey and COVID-19 Focused Infection Control revisit survey conducted on 4/20/21 are documented in this report. The facility was found to be in substantial compliance with 42 CFR Part §483.80.
Based on interview and record review it was determined the facility failed to provide care and services in a manner that maintained and promoted dignity for 1 of 3 sampled residents (#2). This placed residents at risk for lack of dignity. Finding include:
Resident 2 was admitted to the facility in 2018 with diagnoses including dementia.
Resident 2's 10/14/20 care plan indicated the resident was to have only female caregivers.
a. The point of care report indicated Staff 18 provided incontinent care to Resident 2 on 10/22/20.
On 2/3/21 at 12:46 PM Staff 18 (CNA) stated he provided incontinent care to Resident 2 on 10/22/20 and was unaware Resident 2 was to have female only caregivers. Staff 18 stated he was assigned to resident rooms that were female only caregivers.
b. The point of care report indicated Witness 4 (Former CNA) provided incontinent care to Resident 2 on 10/18/20.
On 2/2/21 at 10:56 AM Witness 4 stated after Resident 2's care plan switched to female caregivers only, there were a couple of instances when he assisted Resident 2 to turn in bed while the resident received incontinent care or bathing care from female staff. He further stated there were occasions when there were only male caregivers working on the hall.
On 2/4/21 at 2:40 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the findings and confirmed Resident 2 was care planned for female only caregivers on 10/14/20.
RESIDENT #2 STILL RESIDES HERE AND HAS HAD ONLY FEMALE CARE SINCE 10/23/2020ASSESSED ALL RESIDENTS WHO REQUIRE FEMALE CARE ONLY. ENSURED RESIDENT RIGHTS HAVE BEEN EXERCISEDDNS/DESIGNEE WILL AUDIT ALL FEMALE CARE ONLY RESIDENTS 3X WEEKLY TO ENSURE PLAN OF CARE IS FOLLOWED FOR 4 WEEKS AND THEN QUARTERLY THEREAFTER. RESULTS OF THESE AUDITS WILL BE BROUGHT TO MONTHLY QAPI AND QTLY QA UNTIL SUBSTANTIAL COMPLIANCE HAS BEEN ACHIEVED
Based on interview and record review it was determined the facility failed to report potential neglect of care to the State Survey Agency within 24 hours for 1 of 3 sampled residents (#12) reviewed for abuse. This placed residents at risk for neglect. Findings include:
Resident 12 admitted to the facility in 2018 with diagnoses including heart failure.
The 12/27/20 MDS indicated Resident 12 had a BIMS of 9 (indicating moderately impaired cognition).
The 7/1/20 facility policy for abuse and neglect defined neglect as " ...failure to provide goods or services necessary to avoid physical harm, pain, mental anguish, or emotional distress.
The 1/12/21 facility burn investigation indicated the following:
*Staff 22 (LPN) was approached by a hospice CNA and was asked if she had seen Resident 12's thigh. Staff 9 (CNA) reported a couple of days ago Resident 12 spilled coffee on her/his leg and there was a burn there.
*Staff 9 reported she worked on Resident 12's hall on 1/9/21 but did not provide direct care to the resident. She saw a towel on the resident's lap but did not look under it and assumed the resident spilled something.
*Staff 24 (CNA) reported on 1/9/21 before lunch she exited a room and Staff 25 (Housekeeper) told her Resident 12 spilled hot water on her/himself. Staff 24 got a towel and put it over her/him and did other rounds. Staff 24 did not report the incident to the nurse.
On 2/8/21 at 2:29 PM Staff 2 (DNS) acknowledged the facility did not report the alleged neglect which occurred on 1/9/21 to the State Agency.
RESIDENT #12 IS STILL IN HOUSE AND CARE PLAN AND KARDEX IS UPDATED AND RELECTING APPROPRIATE INTERVENTIONS FOR STAFF IN PERFORMING CARE FOR THE RESIDENT AND REPORTING ANY ISSUES OR REQUESTS TO THE CHARGE NURSETHERE ARE CURRENTLY NO ALLEGATIONS OF ABUSE OR NEGLECT IN FACILITYALL STAFF WERE IN-SERVICED ON 2/26/2020 FOR ABUSE AND NEGLECT: REPORTING AND INVESTIGATING. STAFF HAVE EXPRESSED AN UNDERSTANDING REGARDING RESPONSE TIME TO ALLEGATIONS OF ABUSE, NEGLECT, EXPLOITATION AND MISTREATMENTADMIN/DNS WILL AUDIT RISK MANAGEMENT DAILY FOR ALLEGATIONS OF ABUSE, NEGLECT, EXPLOITATION OR MISTREATMENT AND REPORT WHEN APPROPRIATE IN ACCORDANCE WITH STATE LAW THROUGH ESTABLISHED PROCEDURES. THIS POC IS INDEFINITE. RESULTS WILL BE PRESSENTED MONTHLY AT QAPI AND QUARTERLY QA.
a. Based on observation, interview and record review it was determined the facility failed to provide supervision for swallowing safety for 1 of 5 residents (# 2) identified at risk for aspiration and who was to be supervised while eating. Resident 2 was observed to be left unattended with her/his meal tray two times during continuous observations. Resident 2 was able to independently feed her/himself. This failure resulted in an immediate jeopardy situation. This placed Resident 2 at risk for aspiration and death. Findings include:
Resident 2 was admitted to the facility in 2018 with diagnoses including dementia.
Resident 2's 1/18/21 physician order indicated Resident 2 was on aspiration precautions, was 1:1 assistance with feeding, was to sit upright to 90 degrees for all oral intake, to feed only when alert, and small bites and sips, no straws.
The 1/26/21 physician note indicated Resident 2 was severely demented and was unable to perform ADLs due to dementia.
The 1/30/21 MDS indicated Resident 2 had a BIMS of 10 (indicating moderate cognitive impairment).
On 2/3/21 Resident 2 was observed to have a pink sign above the bed indicating the resident was on aspiration precautions and required 1:1 supervision with meals, was on a soft and bite size diet, alternate liquids and solids, small bites and sips, and to remain upright 30 minutes after meals.
On 2/3/21 the following was observed during continuous observations:
*8:08 AM Staff 17 (CNA) was observed to set Resident 2's meal tray on the table in front of the resident. Staff 17 explained what the resident had for breakfast and Resident 2 stated she/he did not like it. Staff 17 then asked Resident 2 if she/he wanted a bite of food.
*8:10 AM Staff 17 exited the room and left Resident 2 unsupervised with the meal tray within reach. Resident 2 was not observed to eat while staff was out of the room.
*8:11 AM Staff 17 returned to the room with coffee for Resident 2. Staff 17 offered Resident 2 breakfast again and Resident 2 stated she/he did not like it.
*8:13 AM Staff 17 exited the room again leaving Resident 2 unsupervised with the meal tray within reach. Resident 2 was not observed to eat while staff was out of the room.
*8:15 AM Staff 2 (DNS) came down the hall to deliver this surveyor requested paperwork. Staff 2 was asked by this surveyor to enter Resident 2's room and if Resident 2 should be left unattended with the food tray in front of her/him. Staff 2 stated she was unsure of Resident 2's care plan. Staff 2 stood by the resident conversed with her/him and eventually removed the food tray.
*8:18 AM Staff 17 returned to the room with an alternative meal and acknowledged she should not have left the food tray in reach of Resident 2 who was to be supervised with meals. The resident was observed to use her/his utensils and eat eggs independently while Staff 17 observed.
On 2/3/21 at 9:03 AM Staff 19 (RNCM) stated Resident 2 was on aspiration precautions and required 1:1 assistance for cueing and aspiration precautions. Staff 19 further stated the resident aspirated a couple of times in the past and the resident was on 1:1 precautions for approximately the last year.
On 2/3/21 at 9:37 AM Staff 17 stated she thought Resident 2 was on 1:1 supervision to cue the resident to eat. She stated she worked different halls and was unaware of the resident's care plan for aspiration precautions. Staff 17 stated she did not see the aspiration precautions sign above Resident 2's bed prior to serving the breakfast meal tray to Resident 2.
On 2/3/21 at 11:30 AM Staff 1 (Administrator) and Staff 2 (DNS) were notified of the immediate jeopardy (IJ) situation and provided a copy of the IJ template related to the facility's failure to ensure residents were adequately supervised during 1:1 supervision for meals. An immediate plan of correction (POC) was requested.
On 2/3/21 at 12:20 PM the facility submitted a plan of correction.
The IJ Removal Plan included:
- Education was completed for Staff 17.
-The five residents on 1:1 aspiration precautions were audited and care plans and interventions were in place.
-All staff will be in-serviced prior to the beginning of their next shift.
-All new admissions will be assessed upon admit.
-Administrator/DNS/designee will audit charts and care plans.
-All residents will be evaluated no less than quarterly for aspirations risks and care plans will be updated to reflect any changes.
-Staff will be education upon hire and annually on risk factors of aspiration.
-Administrator/DNS/designee will audit five floor staff weekly for one month for aspiration risks and meal tray passes.
On 2/4/21 an addendum was received for the removal plan and included:
-All agency staff will be in-serviced, oriented and submit competencies prior to the beginning of their shift regarding any residents on aspiration precautions or requiring 1:1 feeding. This will be completed by the Administrator/DNS/designee. The agency staff will sign off on in-service and demonstrate back that they understand 1:1 aspiration precautions before their shift begins.
On 2/4/21 a copy of the in-service training was received with staff signatures from 2/3/21.
On 2/4/21 observations were completed during the meal tray pass at lunch. There were no concerns during the observation and it was determined the jeopardy immediacy was removed.
On 2/4/21 Staff 1 was notified the immediacy was removed based on onsite verification that the IJ removal plan was implemented. The IJ removal plan included education for staff members responsible for identifying and assisting residents who were on aspiration precautions and required 1:1 assistance with meals. Observations on 2/4/21 during the lunch meal tray pass indicated staff were trained and assisting residents who required 1:1 assistance with meals due to aspiration precautions.
b. Based on interview and record review it was determined the facility failed to ensure residents were free from accident hazards for 2 of 2 sampled residents (#s 2 and 12) reviewed for accidents. This placed residents at risk for accidents. Findings include:
1. Resident 2 was admitted to the facility in 2018 with diagnoses including dementia.
The 4/29/20 diet order indicated Resident 2 was to receive a limited sodium soft and bite size texture diet.
The 5/17/20 progress note indicated Resident 2 received a peanut butter sandwich with crust and did not comply with the resident's current dietary restrictions. The note further indicated Resident 2 was put on alert charting and monitored.
On 2/2/21 Staff 3 (Registered Dietician) acknowledged a toasted peanut butter sandwich with crust was not an appropriate food for the soft and bite size texture diet.
2. Resident 12 admitted to the facility in 2018 with diagnoses including heart failure.
The 12/27/20 MDS indicated Resident 12 had a BIMS of 9 (indicating moderately impaired cognition).
The 1/12/21 facility burn investigation indicated the following:
*Staff 22 (LPN) was approached by a hospice CNA and was asked if she had seen Resident 12's thigh. Staff 9 (CNA) reported a couple of days ago Resident 12 spilled coffee on her/his leg and there was a burn there.
*Staff 9 reported she worked on Resident 12's hall on 1/9/21 but did not provide direct care to the resident. She saw a towel on the resident's lap but did not look under it and assumed the resident spilled something.
*Staff 24 (CNA) reported on 1/9/21 before lunch she exited a room and Staff 25 (Housekeeper) told her Resident 12 spilled hot water on her/himself. Staff 24 got a towel and put it over her/him and did other rounds. Staff 24 did not report the incident to the nurse.
*Staff 25 reported he was walking down the hall and saw the resident spill a beverage on her/his lap and was said "hot". Staff 25 then went to find someone, and found Staff 24 and notified her.
On 2/5/21 at 1:17 PM and 2/8/21 at 2:52 PM Staff 24 stated one Saturday in mid January the facility was short staffed. She stated she was in the middle of helping a resident, Staff 25 reported to her that Resident 12 spilled hot water and burned her/his left outer side. She stated she had a lot going on, too much to handle and forgot to report it to anyone. She stated Resident 12 had a history of going to the coffee cart and was on thickened liquids. She stated staff often had to redirect the resident or remove the coffee cart out of her/his sight. She stated once Resident 12 would finish a cup of coffee she/he would go back for more.
On 2/8/21 at 1:06 PM Staff 25 stated Resident 12 was right outside of her/his room and had spilled water on her/himself and he gave the resident a towel and notified Staff 24.
On 2/8/21 at 2:52 PM Staff 22 stated she did not work the weekend when Resident 12 initially received a burn. She stated the hospice CNA asked her to look at Resident 12's leg on 1/12/21 and it looked like a burn. Staff 22 stated Resident 12 received brief changes and the skin issues located on her/his leg/hip would have been noticeable during brief changes. Staff 22 stated Resident 12 would attempt to make her/himself coffee and hot cocoa on a daily basis and staff were aware and watched the resident. She further stated the staff would attempt to keep the drink cart out of Resident 12's sight and sometimes move it down the hall so the resident was not able to see it.
On 2/8/21 at 2:29 PM Staff 2 (DNS) stated she completed the investigation for Resident 12 who received a second degree burn. She acknowledged the investigation indicated the burn occurred on 1/9/21 and she was not made aware of it until 1/12/21. Staff 2 acknowledged the burn was noticeable and staff should have noticed it during incontinence care. She state the expectation was for staff to report skin incidents immediately to her.
. Res. # 2 is still in facility. Education was provided for agency staff working with resident # 2 approximately 8:30am. Agency signed Kardex and expressed that she understood 1:1 aspiration precaution. Res. # 2 care plan has been reviewed to reflect aspiration risk with appropriate interventions. The 5 other residents on 1:1 aspiration precaution have also been audited and have appropriate care plans and interventions in place. All current residents will be assessed for risk of aspirations/meal tray passes, care plans will be established, precautions if warranted will be put in place within the next 24 hours. All staff will be in-serviced prior to beginning of their next shift, starting today 2/3/21 with Evening shift and DAY shift CNA’s, Licensed Nurses, and Medication aids. This will ensure that all staff is being re-educated immediately. This will be completed by DNS/Admin or designee.All new admissions will be assessed upon admit for any risk factors of aspiration/meal tray pass. Any issues noted will be placed on care plan and resident info. Will put information in Aspiration Binder and Kardex for floor staff to read. Walking rounds will occur for 2 meals 5 times per week to assure that aspiration precautions are being followed. This will occur for 5 weeks times 1 month and then 1 time per month with results brought to QAPI for 2 quarters or until substantial compliance is met. These audits will be completed by Admin/DNS or designee.Admin/DNS or designee will audit 3 resident charts weekly for one month for aspiration risks and care plans. These audits will continue for 3 months with results brought QAPI for 2 quarters or until substantial compliance is met.All residents will be evaluated no less often than quarterly for aspiration risks and care plans will be updated to reflect any changes.Staff will be educated upon hire and annually on risk factors of aspiration and proper protocol for this situation.All agency staff will be in-serviced, oriented and submit competencies prior to the beginning of their shift regarding any residents on aspiration precautions or requiring 1:1 feeding. This will be completed by Admin/DNS or designee. The agency staff will sign off on in-service and demonstrate back that they understand 1:1 aspiration precautions before their shift begins.
Based on observation, interview and record review it was determined the facility failed to provide sufficient nursing staff to ensure residents attained or maintained their highest practicable mental, physical and psychosocial well-being for 3 of 3 halls reviewed for staffing. This placed residents at risk for unmet needs. Findings include:
1. On 2/3/21 Staff 2 (DNS) provided a list of residents (#s 2, 3, 6, 7 and 8) who were at risk for aspiration and required one to one (1:1, staff assistance) for meals.
On 2/4/21 at 12:08 PM Staff 16 (CNA) was observed assisting Resident 6 during lunch on the 100 hall.
On 2/4/21 at 12:19 PM Staff 16 (CNA) was observed in a different room assisting Resident 7 during lunch on the 100 hall.
On 2/4/21 at 12:22 PM the lunch meal cart was delivered on the 300 hall.
On 2/4/21 at 12:47 PM meal trays were delivered to Resident 8 and Resident 3 on the 300 hall and staff began 1:1 meal assistance for both residents.
On 2/4/21 at 1:18 PM Staff 21 (CNA) stated there were staffing issues during day shift and there had been multiple times residents were not provided meals or assistance with meals in a timely manner.
On 2/4/21 at 1:38 PM Staff 16 (CNA) stated there were "consistent" issues with staffing during day shift, including assisting residents with eating. He further stated some residents took longer to eat than others so other residents had to wait longer for assistance with meals. He acknowledged Resident 7 had to wait until Resident 6 was done eating to be assisted with lunch.
On 2/4/21 at 1:58 PM Staff 22 (LPN) stated there were staffing issues on day shift "all the time." Staff 22 stated residents who needed eating assistance waited an hour or longer for their meals due to staffing issues. Staff 22 further stated call lights took longer to be answered during meals because so many residents required 1:1 eating assistance from staff.
2. On 2/5/21 at 9:27 AM Resident 11 stated she/he was supposed to receive range of motion three times per week but was lucky to receive it three times per month. Resident 11 stated the Restorative Aides are often pulled to work the floor as CNAs due to staffing issues.
On 2/5/21 at 1:17 PM Staff 24 (CNA) stated she was able to provide restorative therapy to residents on one occasion last week and no occasions this week due to being pulled to the floor to work as a CNA because of a shortage of staff. Staff 24 stated she was unable to provide range of motion exercises for residents on a regular basis due to staffing issues and having to work the floor as a CNA.
On 2/8/21 at 2:29 PM Staff 2 (DNS) stated restorative aides are pulled to work as CNA staff on floor due to staffing shortages.
RESIDENT 11 STILL RESIDES IN THE FACILITY. THE DAYS INDICATED IN THE 2567 THAT CNA RATIO WERE NOT MET CANNONT BE CORRECTED. ONGOING RECRUITMENT AND CERTIFICATION WILL CONTINUE FOR QUALITFIED NURSING AIDS WHO MEET THE REQUIREMENTS TO MOVE ON IN THE HIRING PROCESS. FACILITY HAS INITIATED AGENCY STAFFING TO ASSIST IN MEETING RATIOSSTAFFING DIRECTOR INITIATED RECRUITMENT AND RETENTION PLANTHE DNS OR DESIGNEE WILL AUDIT THE DAILY STAFFING FORMS 5 TIMES A WEEK FOR ONE MONTH TO ENSURE THAT CNA RATIO IS BEING MET IN ACCORDANCE WITH F725. FINDINGS WILL BE REVIEWED IN MONTHLY QAPI MEETING AND QUARTERLY THEREAFTER WITH ACTION PLANS, RECRUITMENT PLANS DEVELOPED FOR TENDS IDENTIFIED.
Based on interview and record review it was determined the facility failed to ensure residents received restorative therapies as indicated for 1 of 1 sampled residents (#11) reviewed for rehab services. This placed residents at risk for a decline in ADLs. Findings include:
Resident 11 admitted to the facility in 2012 with diagnoses including multiple sclerosis.
The 10/23/20 MDS indicated Resident 11 had a BIMS of 15 (indicating cognitively intact).
The 9/28/17 restorative nursing plan indicated Resident 11 was to be offered restorative therapy three times per week.
On 2/5/21 at 9:27 AM Resident 11 stated she/he wished to receive range of motion exercises. The resident further stated she/he was supposed to receive range of motion three times per week but was lucky to receive it three times per month. Resident 11 stated the Restorative Aides were often pulled to work the floor as CNAs due to staffing issues. Resident 11 further stated she/he had declined and could no longer move her/his arms without assistance.
On 2/5/21 at 1:17 PM Staff 24 (CNA) stated she was able to provide restorative therapy to residents on one occasion last week and no occasions this week due to being pulled to the floor to work as a CNA because of a shortage of staff. She stated Resident 11 could benefit from having regular restorative therapy and could no longer feed her/himself or complete oral care without assistance. Staff 24 stated she was unable to provide range of motion exercises regularly due to staffing issues and having to work the floor as a CNA.
The 10/27/20 Comprehensive Plan of Care Review indicated Resident 11 was on a restorative plan and had limited range of motion due to advancing multiple sclerosis.
Resident 11's electronic health record indicated she/he received restorative therapy on three occasions in the past 28 days. There was no documentation indicating the resident refused.
On 2/8/21 at 2:29 PM Staff 2 (DNS) stated restorative aides are pulled to work as CNA staff on the floor and acknowledged documentation indicated Resident 11 received restorative therapy three times in the past 28 days.
• RESIDENT 11 STILL RESIDES IN THE FACILITY AND IS STILL ON A RESTORATIVE SERVICE PROGRAM. • FACILITY CONDUCTED A FULL FACILITY AUDIT AND REVIEWED ALL RESIDENTS IN FACILITY WHO HAVE OR SHOULD HAVE RESTORATIVE SERVICES WITH REHAB DIRECTOR, RCMS, ACTIVITY DIRECTORY AND DNS ON 2/24/2021• THE FACILITY WILL ENSURE THAT RESIDENTS WILL RECEIVE RESTORATIVE NURSES SERVICES ACCORDING TO THEIR PLAN OF CARE BY REVIEWING RESTORITIVE DOCUMENTATION DAILY DURING STAND UP MEETING. ANY MISSED SCHEDULED DAYS WILL BE MADE UP DURING THE WEEK.• THE DNS OR DESIGNEE WILL AUDIT THE RA PROGRAM WEEKLY FOR THREE MONTHS TO ENSURE THAT RA IS BEING DONE IN ACCORDANCE WITH THEIR CARE PLAN. FINDINGS WILL BE REVIEWED IN MONTHLY QAPI MEETING AND QUARTERLY THEREAFTER UNTIL SUBSTANTIAL COMPLIANCE IS MET.
Based on observation, interview, and record review it was determined the facility failed to ensure Personal Protective Equipment (PPE) to help prevent transmission of COVID-19 was stored in a sanitary manner and failed to use Environmental Protection Agency (EPA) disinfecting wipes for surfaces in the 200 hall, 300 hall and the designated COVID-19 unit. This placed residents at increased risk for COVID-19 infection. Findings include:
According to CDC.gov, the PPE recommended when caring for a patient with suspected or confirmed COVID-19 includes the following:
Eye Protection:
*Reusable eye protection (e.g., goggles) must be cleaned and disinfected according to manufacturer's reprocessing instructions prior to re-use. Disposable eye protection should be discarded after use unless following protocols for extended use or reuse.
Selected Options for Reprocessing Eye Protection:
Adhere to recommended manufacturer instructions for cleaning and disinfection. When manufacturer instructions for cleaning and disinfection are unavailable, such as for single use disposable face shields, consider:
Reprocessing steps:
* Carefully wipe the inside and then the outside of the visor using a clean cloth saturated with neutral detergent solution, rinse if needed.
* Carefully wipe the outside of the visor using a clean cloth or wipe saturated with hospital disinfectant solution; be sure it remains wet for the required contact time.
*Wipe the outside of visor with clean water to remove residue.
* Fully dry (air dry or use clean absorbent towels).
1. On 1/26/21 at 11:26 AM non-EPA approved wipes were observed on the medication cart in the 200 hall. Staff 27 (LPN) stated they were the only wipes on the cart and if she needed EPA wipes she had to get them from a different medication cart.
On 1/26/21 at 1:20 PM Staff 23 (LPN) and Staff 16 (CNA) were observed working on the COVID-19 unit. Non-EPA wipes were observed next to the exit door and outside of a COVID-19 positive resident room. Staff 23 and Staff 16 acknowledged the wipes were used to clean face shields upon exiting the COVID-19 resident room and upon exiting the COVID-19 positive unit. Staff 23 and Staff 19 were unsure if the wipes were EPA approved wipes. Face shields were observed stored in paper bags next to the exit door, some were not labeled with staff names. Staff 23 acknowledged face shields were to be stored in plastic bags and there were face shields stored in paper bags. Staff 16 was unaware that face shields were to be stored in plastic bags.
On 1/26/21 at 3:10 pm Staff 2 (DNS) confirmed the facility was not using EPA approved wipes on the 200 hall medication cart and two locations inside the COVID-19 positive unit. Staff 2 further acknowledged face shields were stored in paper bags and not in the recommended plastic bags.
According to CDC.gov Operational Considerations for Personal Protective Equipment in the Context of Global Supply Shortages for Coronavirus Disease 2019 (COVID-19) Pandemic: non-US Healthcare Settings: Emergency Considerations for PPE, Updated Nov. 19, 2020:
For limited supplies:
Eye Protection Reuse:
-After reprocessing, a face shield should be stored in a transparent plastic container and labeled with the Health Care Worker's (HCW) name to prevent accidental sharing between HCW.
N95 respirators Reuse:
- One potentially effective strategy to mitigate the contact transfer of pathogens from the respirator to the wearer could be to issue each HCP who may be exposed to patients with SARS-CoV-2 infection a minimum of five respirators. Each respirator will be used on a particular day and stored in a breathable paper bag.
2. On 1/26/21 at 11:01 am Staff 28 (LPN) was observed in the break room. Her face shield was sitting next to her on the table the ear pieces of the shield facing toward the ceiling and an N-95 mask was sitting on inside of the face shield. Staff 28 stated she wore the face shield and did not clean it prior to setting it on the table. Staff 28 stated the N-95 mask was new and had not yet been worn. Staff 28 acknowledged the clean N-95 was resting on the unsantized face shield.
On 1/26/21 at 3:10 pm Staff 2 (DNS) acknowledged staff were to be using EPA wipes to sanitize face shields and acknowledged staff should not store new N-95 masks on non-sanitized face shields.
3. On 1/27/21 at 10:54 AM Staff 8 (Agency CNA) stated CNA staff brought in their own resident care equipment because there were very few thermometers and pulse oximeters available for use. Staff 8 stated he cleaned the equipment with EPA wipes and took it home and used it at a different facility.
On 1/27/21 at 11:20 AM Staff 8 was observed to exit room 310 wearing an N-95 mask and face shield. Signs on the door indicated staff were to use PPE due to the resident being on isolation precautions. Staff 8 did not sanitize his face shield upon exiting the room and started down the hall toward a different resident's room. Staff 8 acknowledged he did not clean his face shield upon exiting the room. Staff 8 then sanitized his face shield and stated face shields should be sanitized when exiting isolation rooms.
On 1/28/21 at 12:46 PM Staff 1 (Administrator) stated the expectation is that staff sanitize face shields after exiting isolation rooms and resident care equipment be cleaned with EPA wipes and remain inside the facility.
FACILITY WIDE AUDIT FOR NON-EPA APPROVED WIPES WAS COMPLETED ON 1/26/2021. THERE ARE ONLY EPA APPROVED WIPES IN THE FACILITY.DNS/ADMIN/DESIGNEE WILL AUDIT 100,200, AND 300 HALLS 3X WEEKLY FOR 4 WEEKS TO ENSURE ONLY EPA APPROVED WIPES ARE AVAILABLE FOR USE. RESULTS WILL BE PRESENTED MONTHLY AT QAPI AND QUARTERLY QA. ALL STAFF WERE IN-SERVICED ON USE OF EPA APPROVED WIPES, PROPER PROCEDURE TO DISINFECT FACE SHIELDS, PROPER STORAGE OF FACE SHIELDS/N95 MASKS AND USE OF PERSONAL VITALS EQUIPMENT IN FACILITY ONLYDNS/DESIGNEE WILL AUDIT 5 STAFF WEEKLY FOR 4 WEEKS TO ENSURE PROPER SANITIZATION OF PPE IN FACILITY. RESULTS WILL BE PRESENTED MONTHLY AT QAPI AND QUARTERLY QA. MAINTENANCE DIRECTOR CREATED AN EXPANSION TO STAFF CHECK IN/OUT AREA TO ENSURE PROPER INFECTION CONTROL PERFORMED. THIS INCLUDES INDIVIDUAL STATIONS AND AN AREA FOR STORAGE/LABELING OF PPE PER EMPLOYEE AT FACILITY
A COVID-19 Infection Control Survey and health complaint (intake #s 24766, 25603 and 25744) were conducted by the Oregon State Survey Agency on 1/26/21 to 2/8/21.
Total residents: 51
Deficiencies were cited.
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 Dietitian
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care Manager
SA: State Agency
SLP: Speech Language Pathologist
TAR: Treatment Administration Record
tid: three times a day
UA: Urinary Analysis
UTI: Urinary Tract Infection
The findings of the complaint (Intake #s 24766, 25603 and 25744) health revisit survey and COVID-19 Focused Infection Control revisit survey conducted on 4/20/21 are documented in this report. The survey was conducted to determine compliance with OAR 411 - 85 through 89.
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 Dietitian
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care Manager
SA: State Agency
SLP: Speech Language Pathologist
TAR: Treatment Administration Record
tid: three times a day
UA: Urinary Analysis
UTI: Urinary Tract Infection
A COVID-19 Infection Facility Review and Complaint (Intake #s 24766, 25603 and 25744) Revisit Survey was conducted by the Oregon State Survey Agency on 5/14/21.
The facility was found to be in compliance with OAR 411-85 through 89.
Total Census: 51
Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing ratios were maintained for 31 days reviewed for minimum CNA staffing. This placed residents at risk for delayed care. Findings include:
A review of the facility's Direct Care Staff Daily Reports from 12/26/20 through 1/25/21 revealed the following dates when the required state minimum CNA staffing ratios were not met for one or more shifts:
-12/27/20
-12/28/20
-12/30/20
-12/31/20
-1/2/21
-1/3/21
-1/4/21
-1/5/21
-1/6/21
-1/7/21
-1/8/21
-1/9/21
-1/10/21
-1/11/21
-1/12/21
-1/13/21
-1/14/21
-1/15/21
-1/16/21
-1/17/21
-1/20/21
-1/21/21
-1/22/21
-1/23/21
-1/24/21
-1/25/21
On 2/4/21 at 2:46 PM Staff 1 (Administrator) acknowledged the lack of required CNAs on duty on the identified dates.
• ONGOING RECRUITMENT AND CERTIFICATION WILL CONTINUE FOR QUALITFIED NURSING AIDS WHO MEET THE REQUIREMENTS TO MOVE ON IN THE HIRING PROCESS. • FACILITY HAS INITIATED AGENCY STAFFING TO ASSIST IN MEETING MINUMUM STAFFING RATIOS• STAFFING DIRECTOR INITIATED RECRUITMENT AND RETENTION PLAN• THE ADMINISTRATOR OR DESIGNEE WILL AUDIT THE DHS DAILY STAFFING FORMS 5 TIMES A WEEK FOR THREE MONTHS TO ENSURE THAT CAN STAFFING RATIO IS BEING MET IN ACCORDANCE WITH OAR MINIMUM CNA RATIO. FINDINGS WILL BE REVIEWED IN MONTHLY QAPI MEETING AND QUARTERLY THEREAFTER WITH ACTION PLANS, RECRUITMENT PLANS DEVELOPED FOR TRENDS IDENTIFIED. THIS WILL CONTINUE UNTIL SUBSTANTIAL COMPLIANCE HAS BEEN ACHIEVED.
Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing ratios were maintained for 12 of 22 days reviewed for minimum CNA staffing. This placed residents at risk for delayed care. Findings include:
A review of the facility's Direct Care Staff Daily Reports from 3/29/21 through 4/19/21 revealed the following dates when the required state minimum CNA staffing ratios were not met for one or more shifts:
-4/4/21
-4/5/21
-4/6/21
-4/9/21
-4/10/21
-4/11/21
-4/12/21
-4/15/21
-4/16/21
-4/17/21
-4/18/21
-4/19/21
On 4/20/21 at 11:58 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the lack of required CNAs on duty on the identified dates.
no new POC required
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OAR 411-085-0310 Residents' Rights: Generally
Refer to F550
******************************
OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care
Refer to F689
******************************
OAR 411-085-0360 Abuse
Refer to F609
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OAR 411-086-0100 Nursing Services: Staffing
Refer to F725
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OAR 411-086-0220 Rehabilitative Services
Refer to F825
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OAR 411-086-0330 Infection Control & Universal Precautions
Refer to F880
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