The findings of the complaint (Intake #s 20316, 27891, 28017, and 28298) health survey conducted 2/8/21 through 3/15/21 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 10 current residents and 4 closed records. The facility had a census of 47 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 #s 20316, 27891, 28017, and 28298) health survey conducted 4/27/21 through 5/3/21 are documented in this report. The survey was conducted to determine compliance with 42 CFR Part §483 Requirements for Long Term Care Facilities.
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# 20316, 27891, 28017, and 28298) health survey conducted 6/17/21 are documented in this report. It was determined the facility was in compliance with 42 CFR Part §483 Requirements for Long Term Care Facilities.
1. Based on interview and record review it was determined the facility failed to provide consistent care, accurately assess, treat, and monitor skin for 1 of 3 sampled residents (#7) reviewed for non-pressure skin wounds. This placed residents at risk for worsening skin conditions.
Resident 7 was admitted to the facility 2/2020 with diagnoses including infection of the skin.
A 6/9/2020 Wound Evaluation revealed Resident 7 had facility acquired MASD (moisture associated skin damage) to the groin.
A 11/29/20 Quarterly MDS revealed Resident 7 was always incontinent of bladder and frequently incontinent of bowel.
A 12/12/20 Skin and Wound Total Body Skin Assessment revealed Resident 7 had normal skin color with no new wounds.
A 12/2020 Documentation Survey Report revealed from 12/17/20 through 12/31/20 the following:
Bladder and bowel elimination:
-Day shift: No documentation care was provided on seven instances.
-Evening shift: No documentation care was provided on 10 instances for bladder and 12 instances bowel.
-Night shift: No documentation care was provided on five instances.
Skin Observation:
Day shift: No skin observation completed on seven instances. A red area on 12/25/20 and 12/30/20 which was not a new skin condition.
Evening shift: No skin observation completed on 12 instances. One instance a red area with discoloration on 12/21/20 which was not new and red area on 12/22/20. One instance documented as "NA".
Night shift: No skin observation completed on five instances. A red area which was not new was documented on 12/19/20 and 12/23/20. Two instances documented as "NA" on 12/30/20 and 12/31/20
A 12/2020 TAR instructed staff to complete a head to toe skin check every week and document the results on Skin and Wound Total Body Assessment every evening shift every Saturday. On 12/19/20 Staff 27 (LPN) documented to review nurses' notes.
A review of nurses' notes, and the Skin and Wound Total Body Assessment revealed no documentation for 12/19/20 by Staff 27.
An Infection Report Initial dated 12/29/20 revealed onset date of symptoms 12/29/20 of a facility acquired skin/wound with redness, nystatin cream (anti-fungal) topically two times a day. The report did not indicate the location of the redness.
A 1/2021 TAR instructed staff to apply nystatin cream to the groin topically two times a day for skin management for 14 days with a start date of 12/29/20.
On 2/9/21 at 3:53 PM Staff 7 (CNA) stated she worked the COVID-19 unit the end of 12/2020 Resident 7 broke out in the groin area. Resident 7 would state she/he was not wet, and the agency CNAs would not check. Resident 7 would state she/he was not wet even if she/he was. Resident 7's groin area redness became worse than it normally was.
On 2/17/21 at 11:49 AM Staff 25 (CNA) stated by the end of 12/2020 Resident 7's entire groin area was swollen.
On 2/18/21 at 11:15 AM Staff 23 (CNA) stated the end of 12/2020 Resident 7's groin area was "horrible".
On 2/19/21 at 9:07 AM Staff 27 (LPN) stated on 12/19/20 she must have missed documenting Resident 7's total body assessment.
On 3/2/21 at 2:43 PM Staff 54 (Infection Preventionist acting DNS) confirmed incontinent care in 12/2020 was not documented for Resident 7 over 20 instances. Staff 54 confirmed there was no documentation of a head to toe skin assessment completed on 12/19/20. Staff 54 stated the 12/29/20 Infection Report did not require a location to be listed for Resident 7's redness and was intended for the required medication and precautions. Staff 54 stated it was a reference to a yeast infection.
2. Based on interview and record review it was determined the facility failed to follow physician orders for medications for 3 of 8 sampled residents (#s 2, 5 and 7) reviewed for safe environment and medications. This placed residents at risk for worsening skin conditions and delayed medication administration. Findings include:
On the evening medication administrations for 2/22/21, clinical records indicated the following:
Resident 7 was admitted to the facility in 2/2020 with a diagnosis including diabetes.
A 2/2021 MAR instructed staff to administer the following medications 2/22/21:
-8:00 PM: Doxazosin Mesylate (treat high blood pressure) tablet four milligrams at bedtime for hypertension with a start date of 2/7/21.
-8:00 PM: Potassium Chloride (supplement to treat low potassium) one tablet at bedtime for supplement with start date of 2/7/21
-8:00 PM: simvastatin (lower cholesterol) at bedtime 20 milligrams for hyperlipidemia (high concentration of fats in the blood) with a start date of 2/7/21.
-8:00 PM: senna plus (laxative) two times a day for bowel care with a start date of 2/7/21.
-10:00 PM: clonidine (treat high blood pressure) one tablet every 8 hours for hypertension with a start date of 2/8/21.
The above medications were not documented as administered.
A 2/2021 TAR instructed staff to administer the following medications on 2/22/21:
-8:00 PM: insulin glargine (to treat high blood sugars) 62 units at bedtime with a start date of 2/12/21.
-8:00 PM: removal of TED (stockings that prevent blood clots) hose, monitor for skin for signs and symptoms of breakdown with a start date of 2/8/21.
-Evening: Clotrimazole-Betamethasone Cream (to treat fungal skin infections) apply to affected area topically every day and evening shift for rash with a start date of 2/8/21.
The above treatments were not documented as administered on 2/22/21.
Resident 5 was admitted to the facility in 1/2015 with a diagnosis including arthritis and anxiety.
A 2/2021 MAR instructed staff to administer the following medications on 2/22/21:
-7:00 PM: ascorbic acid (supplement to treat low levels vitamin C) one tablet one time a day for wound healing with a start date of 1/15/21.
-8:00 PM: Coumadin (treat blood clots) 2 mg in evening on Tuesday, Thursday, Saturday, and Sunday for atrial fibrillation with a start date of 2/22/21.
-8:00 PM: Carvedilol (treat high blood pressure) tablet 6.25 milligram one table two times a day for hypertension start date 1/5/21.
-8:00 PM: Morphine Sulfate (treat pain) 15 milligrams one tablet two times a day for pain with a start date of 1/11/21.
The above medications were not documented as administered.
A 2/23/21 Alert Note revealed there was an alert for Resident 5's medication not documented on the 2/22/21 PM shift. The on-call physician was notified and requested vitals every four hours for 24 hours.
Resident 2 was admitted to the facility in 9/2017 with a diagnosis including hyperlipidemia (abnormally elevated levels of any or all lipids or lipoproteins in the blood) and anxiety.
A 2/2021 MAR instructed staff to administer the following medications on 2/22/21:
-8:00 PM melatonin (to treat insomnia) 3 milligrams at bedtime with a start date of 12/24/20.
-8:00 PM senna-docusate sodium (treat constipation) 8.6-50 milligrams two tablets by mouth for constipation with a start date of 6/4/20.
-8:00 PM Simvastatin (lower cholesterol) 10 milligrams by mouth in evening for hyperlipidemia (high amounts of fat in the blood) with a start date of 7/20/19.
The above medications were not documented as administered.
A 2/23/21 Alert Note revealed there was an alert for Resident 2's medication not documented on the 2/22/21 PM shift. The on-call physician was notified and requested vitals every four hours for 24 hours.
On 3/10/21 at 12:23 PM, 3/12/21 at 7:32 AM and 1:24 PM Staff 54 (Infection Preventionist Acting DNS) stated on 2/22/21 the nurse had a medical emergency. The facility could not determine which medications were administered to residents and which were not.
On 3/12/21 at 12:30 PM Staff 70 (Nurse Practitioner) stated the facility informed him Staff 69 had to leave the facility due to a medical emergency. It was unclear which medications she had administered to the residents. Staff 70 stated he was told Staff 69 had a history of not documenting when preparing mediations. Staff 70 stated he was informed Staff 69 had been in and out of multiple rooms and he gave the order to hold the medications and place the residents on alert monitoring for the wing Staff 69 was working.
On 3/12/21 at 1:56 PM Staff 69 (LPN) stated before work she did not feel well and felt dizzy and nauseated. Staff 69 stated when she arrived for work, she indicated no symptoms during COVID-19 screening. Staff 69 stated she had only administered one resident their medications, she did not have any confusion and she did not dispense multiple resident's medications before administration.
Corrective Actions: (A)1. Resident 7 was assessed by an RN on 4/8/2021. Resident 7s non-pressure skin concerns were reviewed and are being treated based on physician orders. Incontinence care is being provided as needed.2. Pressure injuries have been assessed and reviewed by PCP. Determined to be a fungal infection and medical record was updated and treated per provider orders.Corrective Actions: (B) 3. Resident # 2 was assessed by a RN on 04/08/2021.4. Resident # 5 was assessed by a RN on 04/08/2021.5. Residents 2, 5 and 7 are receiving medications and treatments as ordered.Identification others at risks: (A) 1. A baseline audit will be conducted to verify that skin assessments and treatments are being completed as scheduled. Identified concerns will be addressed.2. Director of Nursing or designee to conduct a baseline audit of incontinence care documentation to determine if incontinence care has been provided as per Point of Care tasks. Identification of Others at Risk: (B)3. Director of Nursing and/or designee to conduct a baseline audit of order administration records for the month of March to determine if other orders were not followed. Audit will include MAR/TARNewly identified concerns will be addressed:Systemic Changes: (A)1. Director of Nursing and/or designee initiated education on March 29, 2021 with nursing staff regarding bowel and bladder care and documentation, to include ensuring cares are documented in the POC (Point of Care).2. Director of Nursing and/or designee will re-educate LNs, beginning on April 13, 2021, related to conducting and documenting skin assessments according to schedule and administering treatments according to physician orders.Systematic Changes: (B) 3. Director of Nursing and or designee to initiate education with Licensed Nurses and Certified Medication Aides on March 29, 2021 regarding following provider orders and ensuring documentation is entered into Point Click Care in the medication administration document. Include content and sign-in sheets for educationMonitoring for compliance: (A) Director of Nursing and or designee to review POC compliance weekly x 3 weeks and monthly x 3 to validate that tasks have been documented and validate that incontinence cares have been provided. Monitoring for compliance: (B) Director of Nursing and/or designee to audit MAR/TAR weekly x 4 and monthly x 3 to verify orders were followed according to provider and are documented in Point Click Care. Director of Nursing and/or designee will audit the Skin and Wound Total Body Assessments to verify completion as scheduled weekly x 4 and monthly x 3. DON and/or designee will analyze audits and results will be reported to the QAPI committee for review and recommendations monthly x 3 months to ensure compliance and sustainability.
Based on observation, interview and record review it was determined the facility failed to follow physician orders for medications for 2 of 3 sampled residents (#s 2 and 5) reviewed for medications. This placed residents at risk for a delay in medication administration. Findings include:
1. Resident 2 was admitted to the facility in 9/2018 with a diagnosis including diabetes and mild protein calorie malnutrition.
An 4/2021 MAR instructed staff to administer Arginaid Packet (nutritional supplement) one time a day for wound healing with a start date of 1/27/21. On 4/27/21 and 4/28/21 the MAR instructed the reader to read progress notes.
4/27/21 and 4/28/21 Administration Notes revealed the Arginaid packet was out of stock in the facility. On 4/28/21 the note stated central supply was aware.
On 4/28/21 at 11:10 AM a sign posted next to central supply revealed central supply was closed on Wednesdays.
On 4/28/21 at 11:16 AM Staff 41 (LPN) stated when central supply was closed, she wrote what was needed on the central supply white board and then had to wait. Staff 41 stated a resident could go two to three days without the needed medications.
On 4/28/21 at 11:19 AM Staff 72 (DNS) stated the expected process for a physician ordered supplement if the facility was out of stock would be to notify the registered dietitian and attempt to obtain the product and if they were unable to obtain they would find another comparabel nutritional supplement. Staff 72 was unaware multiple residents did not receive physician ordered Arginaid for two days.
2. Resident 5 was admitted to the facility in 1/2021 with a diagnosis including vitamin deficiency, and pressure ulcer.
An 4/2021 MAR instructed staff to administer Arginaid Packet (nutritional supplement) one time a day for wound healing with a start date of 1/27/21. On 4/27/21 and 4/28/21 the MAR instructed the reader to read progress notes.
4/27/21 and 4/28/21 Administration Notes revealed the Arginaid packet was out of stock in the facility. On 4/28/21 the note stated central supply was aware.
On 4/28/21 at 11:10 AM a sign posted next to central supply revealed central supply was closed on Wednesdays
On 4/28/21 at 11:16 AM Staff 41 (LPN) stated when central supply was closed, she wrote what was needed on the central supply white board and then had to wait. Staff 41 stated a resident could go two to three days without the needed medications.
On 4/28/21 at 11:19 AM Staff 72 (DNS) stated the expected process for a physician ordered supplement if the facility was out of stock would be to notify the registered dietitian and attempt to obtain the product and if they were unable to obtain they would find another comparable nutritional supplement. Staff 72 was unaware multiple residents did not receive physician ordered Arginaid for two days.
Resident # 2 will receive Arginaid as ordered.Resident # 5 will receive Arginaid as ordered.Arginaid stock was received and stocked in facility. Central Supply will remain open seven days per week for staff to be able to access supplies.Baseline review of Treatment Administration Record for residents with orders for supplements since 4/26/2021 to verify residents received supplements as per orders to be initiated on 4/29/21. Identified issues will be addressed.Re-education initiated on 4/28/2021 to Licensed Nurses and Certified Medication Aides regarding process for supplements that are unavailable. Process for communicating needs to Central Supply will now be via the message board and in the book attached; Re-education will be initiated on 4/29/2021 for Nursing Staff and Central Supply Coordinator on the new communication process. Central Supply to remain open seven days per week so staff can access supplies.Director of Nursing and/or designee will audit weekly x4 and monthly x2 to validate that staff are using the communication board and notebook to alert Central Supply of needed supplies.Director of Nursing and/or designee will audit Treatment Administration Records with supplements, 5 charts weekly x 3 months to validate that a sample of residents supplement orders were administered/followed as per orders. Director of Nursing and/or designee will analyze audits and results will be reported to the QAPI committee for review and recommendations monthly x 3 until a lesser frequency is deemed appropriate.
1. Based on interview and record review it was determined the facility failed to ensure a resident's environment remained free from accident hazards for 1 of 4 sampled resident (#6) reviewed for available medical equipment. This placed residents at risk for accidents. Findings include:
Resident 6 was admitted to the facility in 6/1998 with diagnoses including brain damage.
A 3/13/20 Fall CAA revealed Resident 6 was a fall risk due to brain injury, lack of safety awareness, impulse control, and poor vision and she/he needed checked on frequently.
A 9/1/20 care plan revealed Resident 6 was high risk for falls with interventions including bilateral fall mats next to the bed and the bed in the lowest position.
A 10/17/20 care plan revealed Resident 6 had an actual fall on 10/13/20 and to keep the bed in a low position with fall mats to bedside.
On 2/9/21 at 3:53 PM Staff 7 (CNA) stated she worked with Resident 6 on 12/29/20 and 12/30/20. Resident 6 was a fall risk and her/his bed was in the highest position and there were no fall mats beside her/his bed. The bed would not go down due to the age of the bed. There were no other beds available. After a resident discharged Staff 7 and Staff 9 changed out Resident 6's bed.
On 2/16/21 at 9:01 AM Staff 5 (CNA) stated they were unable to raise or lower Resident 6's bed during the last week of 12/2020.
On 2/18/21 at 11:15 AM Staff 23 (CNA) stated on 12/29/20, 12/30/20 and 12/31/21 Resident 6 was in a bed which would not lower or raise. Staff 23 stated was informed by Staff 7 that Resident 6 was a fall risk and her/his bed should be in the lowest position and there should be fall mats next to her/his bed.
On 3/3/21 at 9:28 AM Staff 33 (CNA) stated she worked with Resident 6 and her/his bed would not work. The bed would not go up or down all the way on 12/21/20, 12/22/20 and 12/28/20.
On 3/8/21 at 2:36 PM Staff 54 (Infection Prevention/Covering DNS) stated the expectation of the staff to utilize the TELS system (manages maintenance tasks) when there was a concern with repairs of the beds.
Review of the Work Orders dated 12/1/20 through 1/31/21 revealed no completed work orders for Resident 6's bed.
2. Based on observation and interview it was determined the facility failed to secure 1 of 1 syringe storage carts during random observations. This placed residents unauthorized access to syringes. Findings include:
On 2/8/21 at 1:31 PM a cart with wheels and open yellow bins sitting in the resident's hallway across the hall from central supply revealed multiple bins filled with new insulin syringes and hypodermic needles.
On 2/9/21 at 2:35 PM a cart with wheels and open yellow bins sitting in the hallway across the hallway from central supply revealed multiple bins filled with new insulin syringes and hypodermic needles.
On 2/9/21 at 2:39 PM Staff 10 (Central Supply) stated the last person who worked in central supply made up the cart and there was not room in Central Supply to store the cart. Staff 10 stated the syringes and hypodermic needles would normally be secured in a locked cabinet in the central supply room or in the locked medication room at the nurses' station.
On 2/9/21 at 3:20 PM Staff 2 (DNS) and Staff 58 (Regional Nurse Consultant) stated they would expect the syringes to be kept in central supply and not in the resident's hallway.
Corrective Action1. Resident #6 was moved to a bed that is able to be raised and lowered and fall mats placed next to the bed.2. Equipment syringe storage cart was stored in a safe area. Identification others at risks1. Residents who need a low bed are at risk.A baseline audit was conducted of facility beds to verify that beds could be raised and lowered. No other concerns were identified.2. All residents are at risk due to unsecured storage of supplies. Newly identified concerns will be addressed:Systemic Changes1. Director of Nursing and/or designee initiated education with nursing staff on March 29, 2021 regarding ensuring interventions are in place as per plan of care. 2. Administrator and/or designee will provide education to nursing staff and maintenance staff regarding TELs system and ensuring maintenance needs are entered into TELs system. 3. Director of Nursing and/or designee initiated education to Central Supply and nursing staff regarding safe storage of supplies and potentially hazardous items on 3/29/2021.Include content and sign-in sheets for educationMonitoring for compliance1. Director of Nursing and/or designee will audit a sample of residents to ensure care planned interventions are in place weekly x 4 and monthly x 3. 2. Administrator and or designee will conduct an audit of 20 pieces of equipment weekly x 4 and monthly x 3 to ensure in good working order. DON and/or designee will analyze audits and results will be reported to the QAPI committee for review and recommendations monthly x 3 to ensure compliance and sustainability. Administrator and/or designee will analyze audits and results will be reported to the QAPI committee for review and recommendations monthly x 3 to ensure compliance and sustainability.
Based on 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 1 of 3 sampled residents (#5) reviewed for call light times. This placed residents at risk for unmet needs. Findings include:
Resident 5 was admitted to the facility in 1/2015 with a diagnosis including arthritis and anxiety.
A 12/30/20 Annual MDS revealed Resident 5 was occasionally incontinent of bowel and bladder.
A 2/4/21 care plan revealed Resident 5 had an ADL deficit and required a two-person total assist with toileting.
A 2/22/21 Direct Care Staff Daily Report revealed the following:
Day shift there a census of 52 residents. No registered nurse worked, and seven CNAs worked.
On 2/23/21 at 1:23 PM Witness 4 (family member) stated she was speaking to Resident 5 on the phone from 11:00 AM to 12:20 PM during the time she/he was waiting to use the restroom on 2/22/21. Resident 5 called out to staff after her/his light was not answered. A staff member stated another staff member was required and walked by. Witness 4 was concerned and called the front desk requesting assistance for Resident 5.
On 3/8/21 at 9:18 AM Staff 62 (CNA) stated there were concerns with staffing and felt the staff were "spread thin". Staff 62 stated she was assigned up to 13 residents on day shift and did not always get her breaks and lunches.
On 3/8/21 at 9:10 AM Staff 60 (CNA) stated the facility had some staffing concerns. Staff 60 stated there were some long call light times.
On 3/11/21 at 9:22 AM Staff 66 (Screener) stated in 2/2020 she did receive a call from a concerned family member due to a resident's call light not being answered timely. Staff 66 stated she directed the call to the nurses' station.
On 3/12/21 at 7:39 AM Staff 54 (Infection Preventionist Acting DNS) stated on 2/22/21 the facility was short a CNA for the resident census for the day.
Corrective Action Resident # 5 was assessed by a RN on 04/08/2021Identification others at risksAll residents are at risk for unmet needs regarding insufficient nursing staffing. Administrator and/or designee will conduct a baseline audit of staffing for the prior two weeks to verify if there were other days without sufficient staffing as per Oregon staffing requirements and regulations. Newly identified concerns will be addressed.Systemic ChangesAdministrator to initiate education with the staffing coordinator and Director of Nursing regarding staffing requirements and ratios on April 08, 2021.Include content and sign-in sheets for educationMonitoring for complianceAdministrator and/or designee will audit daily staffing assignments weekly x 4, monthly x 3 to validate sufficient nursing staff as per Oregon staffing and federal regulations. Administrator and/or designee will analyze audits and results will be reported to the QAPI committee for review and recommendations monthly x 3 to ensure compliance and sustainability.
Based on interview and record review it was determined the facility failed to provide staff with appropriate competencies and skills for temporary agency staff for 4 of 5 (#s 20, 23, 25, and 27) temporary agency staff reviewed for facility orientation. This placed residents at risk for unmet needs. Findings include:
A 9/2019 Temporary Agency Staff Orientation Policy and Procedures revealed all temporary agency staff will complete an orientation program to ensure the safety and comfort of all residents were assured. The orientation shall include:
-Explanation of facility organization structure
-Philosophy of care of the facility, including purpose of nursing facility requirements
-Description of resident population
-Employee rules
-Facility policy and procedures.
The Temporary Agency Staff Orientation did not address the orientation and use of electronic health records to complete their daily tasks.
On 2/17/21 at 11:49 AM Staff 25 (CNA) stated she was a temporary agency staff and worked in 12/2020. Staff 25 stated she had not been orientated to the facility when she started work at the facility. Staff 25 stated she just "played it by ear".
On 2/18/21 at 11:15 AM Staff 23 (CNA) stated he was temporary agency staff and worked in the COVID-19 unit in 12/2020 and was not orientated to the facility. Staff 23 stated he never received information to log into the system to document the work he was completing and used other staff's logins to document some of his work.
On 2/18/21 at 2:11 PM Staff 20 (CNA) stated she started working at the facility in 12/2020 and was not oriented to the facility when she started. Staff 20 stated she did not receive computer login information for a couple of days and used another staff member information to document in the computer system.
On 2/19/21 at 2:53 PM Staff 27 (LPN) stated she was temporary agency staff and started working at the facility in approximately 10/2020 and she was expected to work the first day she started. The facility provided a "bit" of orientation, but she was expected to know how to do her job.
On 2/23/21 at 2:07 PM, 3/4/21 at 7:07 AM and 3/5/21 at 9:30 AM Staff 54 (Infection Prevention/Covering DNS) stated no temporary staff orientation records was found for Staff 23, Staff 25, and Staff 27. Staff 54 stated Staff 23 started work on 12/30/20. Staff 54 stated Staff 20 started work at the facility on 12/15/20 and access to medical records on 12/17/20.
An undated handwritten COVID unit document revealed Staff 23 worked on 12/29/20 from 6:00 PM to 6:00 AM.
On 3/2/21 at 6:10 AM orientation documentation was requested from Staff 54 for Staff 20. No additional documentation was received.
On 2/24/21 at 11:04 AM Staff 48 (Staffing Coordinator) stated she was recently made aware of the orientation book along with signature pages for agency staff. Staff 48 stated she started work as an agency staff from 3/2020 through 8/2020 and was not oriented to the facility when she started work.
Corrective Actions:Facility will Ensure agency staff have required orientation with supporting documentation prior to starting on the floor. Residents currently residing at the facility have the potential to be at risk.Administrator and/or designee will complete baseline audit for staff currently working to ensure orientation was completed and documented. Identified issues will be corrected.Process update:Any newly identified concerns will be addressed.Scheduler to create file for each agency to be used and ensure. 1. Orientation2. Building orientation signature3. Computer access to building has been established.4. Covid unit orientation and signatureScheduler will validate covid unit orientation and education for all staff members assigned to unit Prior to start of Shift. Education: Inservice education was completed with scheduler and Infection Preventionist concerning requirement of all agency staff to have in facility record of orientation along with signed facility orientation.Inservice education was completed with scheduler and IP concerning staff working on COVID-19 unit to have signed COVID-19 orientation packet prior to starting shift on unit. Records will be retained by the facility per record retention policies.Administrator/Scheduler/Infection Preventionist were provided education of the requirement of orientation profile, building orientation and covid orientation prior to shift working. Scheduler will be primary responsible to ensure orientation process is followed. Administrator and/or designee will audit schedules vs orientation logs weekly x 4, monthly x 3 and quarterly x 2 to verify that orientation packets completed as per plan and system. Administrator will report to QAPI committee audits, monthly x 3 and quarterly x 2 to validate the above listed corrective actions have been implemented and the correction is being sustained.
Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases, including COVID-19 and infections. The facility failed to ensure staff were screened for symptoms for 5 of 7 staff (#s 4, 7, 20, 23 and 26) reviewed for COVID-19 screening and wear appropriate PPE on a the 2 of 2 (COVID-19 unit) halls.
1. A 12/30/20 COVID-19 Screening Tool revealed Staff 7 (CNA) indicated no for any COVID-19 symptoms. No temperature was documented for Staff 7.
Review of the COVID-19 Screening Tool for 12/30/20 revealed no screenings were completed for Staff 4 (LPN), Staff 20 (CNA), Staff 23 (CNA) and Staff 26 (LPN).
On 2/18/21 at 11:15 AM Staff 23 stated Staff 26 worked the COVID-19 unit while ill and she reported to Staff 23 she had a temperature of 101.5 and did not feel well on 12/29/20, 12/30/20 and 12/31/20.
On 2/19/21 at 9:07 AM Staff 27 (LPN) stated she attempted to send two staff members home on 12/30/20, Staff 26 and one CNA. Staff 26 was teaching Staff 27 about the medication cart and told her she had COVID-19 and she did not feel well. Staff 27 told Staff 26 to go home. Staff 27 stated Staff 26 just looked at her and told her she had been approved to work. Staff 27 stated there was no charge nurse on the COVID-19-unit.
On 2/23/21 at 10:48 AM Staff 8 (CNA) stated she saw both CNAs and nurses working while sick with symptoms in the COVID-19-unit in 12/2020.
On 3/2/21 at 2:55 PM Staff 54 (Infection Preventionist, Acting DNS) stated no COVID-19 screening sheets were found for Staff 4, Staff 20, Staff 23, and Staff 26. Staff 54 stated the facility expected COVID-19 screening of all individuals entering the building.
2. According to CDC.gov the PPE recommendations for use of face masks and eye protection.
HCP (Health Care Professionals) should wear well-fitting source control at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers.
To reduce the number of time HCP must touch their face and potential risk for self-contamination, when used for source control, HCP should consider continuing to wear the same respirator or well-fitting facemask throughout their entire work shift.
The use of eye protection is recommended in areas with moderate to substantial community transmission. On 2/9/21 at 3:30 PM Staff 11 (LPN) was observed in the COVID-19-unit resident hallway with no face shield.
On 2/18/21 at 11:15 AM Staff 23 (CNA) stated on 12/30/21 three nurses and Staff 5 (CNA) did not wear their face shields.
On 2/9/21 at 3:53 PM Staff 7 (CNA) stated when she started working in the COVID-19 unit in 12/2020 there were staff members who were not wearing face shields or masks. Staff 7 stated it was agency staff who had contracted COVID-19 and told her it did not matter as they already had COVID-19 so they did not need to wear the face shield and masks.
On 2/19/21 Staff 27 (LPN) stated in 12/2020 Staff 5 (CNA) preferred not to wear a mask and face shield.
On 2/23/21 Staff 28 (LPN) stated while working in the COVID-19 unit in 12/2020 there were quite a few staff members who did not wear their face shields and masks.
On 2/24/21 Staff 40 (CNA) stated in 12/2020 some of the staff would not gown up before going into the resident rooms. Staff 40 stated they would state they already had COVID-19 and they did not have to gown up.
On 3/2/21 at 2:55 PM Staff 54 (Infection Preventionist Acting DNS) stated it was the expectation of staff to wear a face shield and mask in patient care areas. Staff could remove their masks in designated break area.
Corrective Action Screening1. Facility will ensure screening is completed as per CDC, OHA and CMS guidancePPE1. Personal Protective Equipment will be worn as per CDC, OHA and CMS guidance. Identification others at risksScreening1. Residents currently residing in facility are at risk for being affected by ineffective screening practices.PPE1. Residents currently residing in the facility are at risk for being affected by ineffective PPE use. Newly identified concerns will be addressed:Systemic ChangesScreening 1. Education was initiated to screening staff regarding process for screening and tracking of daily schedules by Regional Infection Preventionist on February 16, 2021 2. Schedules will be provided to screener by Administrator to track who is on the schedule and validate they were screened. PPE 1. Regional Infection Preventionist initiated education with facility staff regarding PPE use to include: when to wear it, donning and doffing and storage/disposal on March 29, 2021.Include content and sign-in sheets for educationMonitoring for complianceScreening1. Administrator and/or designee will review screening logs weekly x 4 weeks and monthly x 3 to validate that screening logs are completed for assigned staff and forms are thorough and complete; also verifying no staff permitted to enter facility if screening was not passed. PPE 1. Director of Nursing and/or designee will audit a sample of staff weekly x 4, monthly x3 to verify staff are donning and doffing PPE and wearing appropriate PPE when indicated utilizing the infection control rounding tool.Administrator and/or designee will analyze audits and results will be reported to the QAPI committee for review and recommendations monthly x 3.DON and/or designee will analyze audits and results will be reported to the QAPI committee for review and recommendations monthly x 3.
Based on interview and record review it was determined the facility failed to ensure the COVID-19 unit was clean for 2 of 2 (COVID-19 Unit) halls reviewed for cleanliness. The facility failed to ensure resident rooms were cleaned after resident's roommate contracted COVID-19 for 1 of 4 (#5) reviewed for infection control for COVID-19. This failure increased the risk for the spread of infection. This placed residents at risk for an unsanitary environment. Findings include:
1. A picture provided by Staff 23 (CNA) who worked in the COVID-19 unit in 12/2020 revealed the COVID-19-unit hallway with the outdoor entrance/exit. Two garbage cans with plastic bags were overflowing over the top with no lids. The garbage can was placed next to a PPE cart. One garbage can contents were touching the top of the PPE cart. On the floor next the PPE cart contents were touching the side of a PPE cart and by the wall was a pile of laundry not contained in a bag. In front of another PPE cart was a plastic bag filled with white items touching the front of the cart. On the handrail above the PPE cart a drinking cup was propped up touching the wall. On the floor closest to the camera there were eight quarter sized dried spill droplets. The floor was dull and did not appear clean.
A picture provided by Staff 23 who worked in the COVID-19 unit in 12/2020 revealed the COVID-19 unit hallway without the outdoor entrance/exit. Next to the nurses' station's door was an open bin with full plastic bags piled on the floor in front of the bin. The pile extended past the middle of the hallway and was approximately a foot away from the PPE cart on the opposing wall. Four incontinent wipe packages were propped on the handrail as well as multiple empty plastic bags hanging over the handrails. On the floor closest to the camera four small unknown debris items were on the floor two in front of a PPE cart. The floor was dull and appeared unclean.
On 2/9/21 at 3:53 PM Staff 7 (CNA) stated in 12/2020 the COVID-19 unit was "nasty", and the facility told the CNAs to be housekeepers. Staff 7 stated the resident's bathrooms were "gross" and it took them about two weeks of yelling at the other staff to get the rooms clean.
On 2/16/21 at 9:01 AM Staff 5 (CNA) stated there were no housekeepers in the COVID-19 unit when he was working in 12/2020. He stated the staff "did what they could". There was no cleaning schedule or organization for cleaning.
On 2/17/21 at 11:49 AM Staff 25 (CNA) stated she worked in the COVID-19 unit in 12/2020. Staff 25 stated there was no housekeeper in the COVID-19 unit. Staff stated she did not know of a cleaning schedule and the staff would do some general sweeping and would clean a room if a resident was discharged.
On 2/18/21 at 11:15 AM Staff 23 (CNA) stated he worked the COVID-19 unit in 12/2020. Staff 23 stated there was no cleaning schedule and no housekeeping on the COVID-19 unit. Staff 23 stated the unit was not clean, when entering resident's rooms the floors were dirty and smelled of urine. The only cleaning supplies available was a bottle of bleach.
On 2/18/21 at 2:11 PM Staff 20 (CNA) stated she worked on the COVID-19 unit in 12/2020. Staff 20 stated the unit was "filthy" and there was no cleaning schedule and no cleaning supplies and no housekeepers. Staff 20 stated it was the night shift's responsibility to clean and it was difficult to clean while residents were sleeping. Staff 20 stated the garbage cans were overflowing, the floors were sticky, and the toilets were dirty. Some staff members were in the break room watching movies.
On 2/23/21 at 9:40 AM Resident 4 stated while she/he was in the COVID-19 unit in 12/2020 no one came into her/his room to clean.
On 2/23/21 at 10:48 AM Staff 8 (CNA) stated the cleanliness of the COVID-19 unit in 12/2020 "sucked" Staff 8 stated the staff did what they could but CNA staff were doing CNA, housekeeping, and maintenance work. Staff 8 stated she walked in one night and there were bags of supplies all over the floor and there was no direction from the unit manager, DNS, or Administrator.
On 2/24/21 Staff 40 (CNA) stated she worked in the COVID-19 unit in 12/2020 and there was no housekeeping in the COVID-19 unit and the CNAs were doing the cleaning. Staff 40 stated they did not have all the needed supplies to clean properly. Staff 40 stated there was no schedule, the floors were sticky, and resident's toilets were dirty due to not having floor cleaner and toilet cleaner.
On 3/2/21 at 5:14 PM Staff 54 (Infection Preventionist Acting DNS) verified no housekeepers were working in the COVID-19 unit in 12/2020. Staff 54 stated it was the responsibility of the nurses on the unit to oversee the cleaning and to ensure cleaning was completed. Staff 54 stated no checklists or documentation was completed to verify cleaning was completed.
On 3/8/21 at 1:58 PM Staff 4 (LPN) stated when she worked in the COVID-19 unit in 12/2020 the unit was "sub-par" for cleanliness. Staff 4 stated there was a lot of trash from the PPE used as well as there was an odor in the unit at times.
2. Resident 5 was admitted to the facility in 1/2015 with a diagnosis including arthritis and anxiety.
A 12/18/20 Resident COVID-19 Testing Report revealed Resident 16 tested positive for COVID-19.
A 12/26/20 Resident COVID-19 Testing Report revealed Resident 5 tested positive for COVID-19.
A Clinical Census revealed Resident 16 moved to the COVID-19 unit on 12/20/20 from the same room Resident 5 was residing.
A Clinical Census revealed Resident 5 was moved from her/his room to the COVID unit on 12/29/21.
On 1/29/21 a public complaint was received which alleged Resident 5's room was not cleaned after Resident 16 was diagnosed with COVID-19 and Resident 5 developed COVID-19.
On 2/9/21 Witness 4 (Complainant) stated the facility did not clean Resident 5's room after Resident 16 was moved from the room on 12/18/20 and Resident 5 contracted COVID-19. Witness 4 stated after Resident 5 moved to the COVID-19 unit the facility placed a halo (disinfection system) unit into the room to disinfect the room.
On 3/9/21 at 9:07 AM Staff 65 (Light Housekeeper) stated if there were two residents in a room and one became positive for COVID-19 they would not go into the room and clean when the resident who did not have COVID-19 still remained in the room.
On 3/9/21 at 9:15 AM Staff 64 (Light Housekeeping) stated if a resident was COVID-19 positive housekeeping would not go into the room and clean until the room was haloed.
On 3/11/21 at 10:04 AM Staff 63 (Housekeeping Manager) stated if there were two residents in a room and one contracted COVID-19 and the other resident did not contract COVID-19 the housekeepers would not go into the room to clean the room.
On 3/12/21 at 7:39 AM Staff 54 (Infection Preventionist Acting DNS) stated two residents were in a room and one contracted COVID-19 the process usually was to treat the room as a deep clean and transfer one resident out of the room and halo the room. Staff 54 stated he was not aware housekeeping staff were not going into the rooms in which a resident was COVID-19 positive.
Corrective Action Facility will ensure a safe, functional, sanitary and comfortable environment. (A) Facility will ensure COVID-19 unit has a system and process in place to verify cleaning is occurring and documented.(B) Facility will ensure rooms will be terminally cleaned as per policy..Identification others at risksResidents currently residing in the facility have the potential to be infected with COVID-19.Newly identified concerns will be addressed:Systemic ChangesA. Regional Infection Preventionist initiated education with staff regarding COVID-19 unit cleaning and record keeping requirements on February 17, 2021 B.Regional Infection Preventionist initiated education with staff regarding steps for cleaning a contaminated patient room if a roommate tests positive on April 09, 2021.Include content and sign-in sheets for educationMonitoring for complianceAdministrator and/or designee will audit cleaning logs for COVID-19 unit, to include general cleaning of unit and terminal cleaning of rooms, weekly x 4 weeks and monthly x 3 months to ensure logs are completed as per policy, and there are no holes in documentation. Administrator and/or designee will audit rooms with transfers and/or discharges weekly x 4 and monthly x 3 to verify terminal cleaning was conducted per policy.Administrator and/or designee will analyze audits and results will be reported to the QAPI committee for review and recommendations monthly x 3 or until a lesser frequency is deemed appropriate.
The findings of the licensure and complaint (Intakes # 20316, 27891, 28017, and 28298) health survey conducted 2/8/21 through 3/15/21 are documented in this report. The survey was conducted to determine compliance with OAR 411- 85 through 89. For additional information refer to the Form CMS 2567 dated 3/15/21.
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 revisit to the licensure and complaint (Intake #s 20316, 27891, 28017, and 28298) health survey conducted from 4/27/21 through 5/3/21 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 5/3/21.
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 health complaint revisit survey (Intake# 20316, 27891, 28017, and 28298) conducted on 6/17/21 are documented in this report. The facility was found to be in substantial compliance with OAR 411 Divisions 85 through 89.
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OAR 411-086-0110 Nursing Services: Resident Care
Refer to F684
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OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care
Refer to F689
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OAR 411-086-0100 Nursing Services: Staffing
Refer to F725 and F726
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OAR 411-86-330 Infection Control and Universal Precautions
Refer to F880
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411-087-0100 Physical Environment: Generally
Refer to F921
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OAR 411-086-0110 Nursing Services: Resident Care
Refer to F684
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