The findings of the complaint (Intake #s 23560, 25312, 26958, 27836 and 28609) health survey conducted 2/23/21 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 4 current residents and 13 closed records. The facility had a census of 82 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 complaint (Intake #s 23560, 25312, 26958, 27836 and 28609) health revisit survey conducted 4/22/21 are documented in this report. The facility was found to be in substantial compliance with 42 CFR Part §483 Requirements for Long Term Care Facilities.
Based on observation and interview it was determined the facility failed to ensure proper storage of biologicals on 4 of 5 treatment carts during random observations. This placed residents at risk for unsafe access to medications and stored biologicals. Findings include:
The New Nursing Medication/Treatment Administration document indicated:
-Keep carts locked when not in full visual sight.
1. On 2/23/21 at 4:25 PM a treatment cart was observed to be unlocked and unattended in the 200 hall.
On 2/23/21 at 4:58 PM Staff 22 (RN) acknowledged the treatment cart was unlocked and unattended and confirmed she should have locked the cart.
2. On 2/25/21 at 12:41 PM a treatment cart was observed to be unlocked and unattended on the east transitional care unit
On 2/25/21 at 12:45 PM Staff 6 (RN) acknowledged the treatment cart was unlocked and unattended and confirmed he should have locked the cart.
3. On 2/25/21 at 11:19 AM a treatment cart was observed to be unlocked and unattended on the west skilled hall.
On 2/25/21 at 11:22 AM Staff 4 (RN) acknowledged the treatment cart was unlocked and unattended and confirmed he should have locked the cart.
4. On 2/25/21 at 3:44 PM a treatment cart was observed unlocked and unattended in the Skilled hall.
On 2/25/21 at 3:44 PM Staff 5 (RN) acknowledged the treatment cart was unlocked and unattended and confirmed she should have locked the cart.
Corrective Action Treatment and medications carts will be kept locked when not in full visual sight of CMA or Licensed Nurse. Identification others at risks DON/designee will complete baseline audit throughout facility to verify that medication and treatment carts are kept locked when not in full visual sight of CMA/LN. Newly identified concerns will be addressed. Systemic Changes DON/designee will initiate education April 1, 2021 for Unit Managers, Licensed nurses and CMA staff related to keeping medication and treatment carts locked when not in full visual sight of CMA/LN. Include content and sign-in sheets for education Monitoring for compliance DON and/or designee will audit weekly x4, monthly x3 to validate that medication and treatment carts are kept locked when not in full visual sight of CMA/LN. DON and/or designee will analyze audits weekly, and results will be reported to the QAPI committee for review and recommendations monthly.
The findings of the complaint (Intake #s 23560, 25312, 26958, 27836 and 28609) health survey conducted 2/23/21 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 complaint (Intake #s 23560, 25312, 26958, 27836 and 28609) health survey conducted 4/22/21 are documented in this report. It was determined the facility was in substantial compliance with OAR 411 - 85 through 89.
**********************************
OAR 411-086-0260 Pharmaceutical Services
Refer to F761
**********************************
