The findings of the complaint (Intake #27828) health survey conducted 2/17/21 through 2/22/21 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 2/22/21.
The sample was comprised of 2 current residents and 1 discharged resident. The facility had a census of 59 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 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 complaint health survey (Intake #27828) conducted on 3/17/21 are documented in this report. The facility was found to be in substantial compliance with 42 CFR Part ยง483 Requirements for Long Term Care Facilities.
Based on interview and record review it was determined the facility failed to accommodate resident staffing preferences for 1 of 3 sampled residents (#1) reviewed for abuse. This placed residents at risk for psychosocial harm. Finding include:
Resident 1 admitted to the facility in 2019 with diagnoses including bipolar disorder and dementia.
The 12/3/20 Quarterly MDS, Section C indicated the resident was cognitively intact but had fluctuating disorganized thinking behaviors.
Witness 1 (Family Member) was listed in the medical record as Resident 1's responsible party.
A Grievance Investigation dated 12/14/20, indicated on 12/11/20 at 4:30 PM Staff 1 (Administrator) received a phone call from Witness 2 (Family Member). Witness 2 stated Resident 1 reported a CNA hit the resident. Resident 1 was interviewed and stated a CNA hit her/him with a wipe in the face. The resident was assessed and there were no marks or injuries. The resident was unable to state when the incident occurred and was only able to recall the first name of the CNA accused. The report indicated there were five facility staff members with the same first name alleged by Resident 1 and the facility was unable to determine which staff member Resident 1 was referring to. The investigation did not determine the allegation of abuse occurred but during the investigation staff members with the first name of the accused were removed from providing cares for Resident 1 during the investigation.
On 2/17/21 at 10:27 AM Witness 1 (Family Member) stated during Resident 1's 12/14/20 care conference the facility agreed to the request for CNA's with the first name of the accused perpetrator to no longer provide care for Resident 1 and two staff members be present for all cares. Witness 1 stated this request was due to Resident 1 reporting to Witness 1 she/he was "scared" of the alleged perpetrator.
Staffing schedules from 12/14/20 through 2/15/21 indicated 20 days when Staff 13 (CNA) or Staff 14 (CNA), who both had the same first name of the accused staff member, were assigned to provide care for Resident 1.
On 2/18/21 at 11:28 AM Staff 13 acknowledged she provided care for Resident 1 during the identified time frame but stated after the alleged incident there were two staff present for all cares. Staff 13 was unaware staff with her same name were not to provide cares for the resident.
On 2/18/21 at 2:53 AM Staff 14 acknowledged she provided care for Resident 1 during the identified time frame but there were always two staff present. Staff 14 was unaware staff with her same name were not to provide cares for the resident.
On 2/22/21 at 11:34 AM Staff 1 (Administrator) acknowledged Witness 1 requested on behalf of Resident 1, no staff members with the same name of the alleged perpetrator were to provide cares for the resident and acknowledged staff members with that name were providing care for the resident after the request was made.
1. Staff with same first name Maria are removed from assignment to Res 1 ADLs cares per Responsible party request, although abuse was not substantiated. All nursing staff informed of the current care plan. 2.All residents have potential to be affected. 3.All other residents Care Plans will be reviewed during scheduled Admissions, Quarterly care conferences, Annual and/or Significant changes of conditions, to assure preferences are noted, agreed with resident representatives and Care Conference IDT team.4. All nursing staff will be notified via Kardex of changes on Care Plan which occurs simultaneously, and changes on resident care plans will be also reported to staff during shifts change report 3x daily. In-service training to nursing staff will be completed to assure continuity of care, Kardex Care Plans by March 12, 2021.5.RCMs, DNS, Administrator, or designee will monitor Care Plans changes and documentation through the 24 hrs. process report system daily and monitor that staff is knowledgeable routinely with audits. Results will be brought to the QA x 3 quarters to assess efficacy.
Based on interview and record review it was determined the facility failed to report an allegation of physical abuse in the required time frame for 1 of 3 residents (#1) reviewed for abuse. This placed residents at risk for abuse. Findings include:
Resident 1 admitted to the facility in 2019 with diagnoses including bipolar disorder and dementia.
The 12/3/20 Quarterly MDS, Section C indicated the resident was cognitively intact but had fluctuating disorganized thinking behaviors.
A Grievance Investigation dated 12/14/20, indicated on 12/11/20 at 4:30 PM Staff 1 (Administrator) received a phone call from Witness 2 (Family Member). Witness 2 stated Resident 1 reported to them a CNA hit the resident in the face. The report further indicated an interview with Resident 1 was conducted on 12/11/20 by Staff 12 (RNCM) after the allegation. Resident 1 stated a CNA hit her/him with a wipe on the face and punched her/him on the mouth and the resident almost fell. The resident was assessed and there were no marks or injuries. The resident was unable to state when the incident occurred and was only able to provide the first name of the CNA.
A Facility Reported Incident (FRI) report was received by the Survey Agency on 12/14/20, four days after the allegation of abuse was made to the facility.
On 2/22/21 at 11: 34 AM Staff 1 (Administrator) confirmed the facility did not report the allegation of abuse within the required time frame.
1. Resident 1 Report was completed and submitted on 12/14/20202. All residents have the potential of being affected. 3. All current staff will be in-serviced on timely Abuse reporting by March 12, 20214. Any resident involved in an incident where Abuse is suspected will have a FRI report submitted within the required timeframe.5. RCMs, DNS, Administrator or designee will monitor that FRI reports are completed and submitted within the required time frame. Completed FRI reports will be brought to the QA meeting x 4 quarters for compliance monitor.
Based on interview and record review it was determined the facility failed to thoroughly investigate and provide documented evidence to rule out potential physical abuse for 1 of 3 sampled residents (#1) reviewed for abuse. This placed residents at risk for abuse. Findings include:
Resident 1 admitted to the facility in 2019 with diagnoses including bipolar disorder and dementia.
The 12/3/20 Quarterly MDS, Section C indicated the resident was cognitively intact but had fluctuating disorganized thinking behaviors.
A Grievance Investigation dated 12/14/20, indicated on 12/11/20 at 4:30 PM Staff 1 (Administrator) received a phone call from Witness 2 (Family Member). Witness 2 stated Resident 1 reported to them a CNA hit the resident in the face. The report further indicated an interview with Resident 1 was conducted on 12/11/20. Resident 1 stated a CNA hit her/him with a wipe on the face and punched her/him on the mouth and the resident almost fell. The resident was assessed and there were no marks or injuries and the resident reported she/he felt safe. The resident was unable to state when the incident occurred and was only able to recall the first name of the CNA accused. The report indicated there were five facility staff members with the same first name alleged by Resident 1.
The facility's undated Abuse Program Policy indicated:
-The abuse investigation would include a statement from staff involved in the residents care as well as from residents and/or visitors who may have information regarding the suspected infraction.
-Anyone interviewed regarding the suspected abuse would be asked to furnish a statement regarding the situation.
Witness Statements were completed on 12/11/20 by Staff 17 (LPN), 12/14/20 by Staff 18 (CMA) and 12/19/20 by Staff 14 (CNA). Only Staff 14 had the same first name of the alleged perpetrator Resident 1 accused of hitting her/him.
There were no other witness statements for the alleged incident provided by the facility.
On 2/22/21 at 11:34 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they were unable to determine which CNA Resident 1 had accused and acknowledged there were no witness statements for the four other staff members with the same first name of the alleged perpetrator.
1. Res 1 reports statements are completed.2. All residents have the potential of being affected 3. All current staff will be in-serviced on completion and submitting Abuse witness statements in a timely manner by March 12, 2021. All new hire staff will be trained during New Hire Orientation on timely witness statements completion and submission to appropriate supervisors.4. RCMs, DNS, Administrator or designee will monitor that written witness statements are submitted within the required timeframe using 24 hr reporting system review. 5. Completed witness statements will be brought to the QA meeting x 4 quarters for compliance monitor.
The findings of the complaint (Intake #27828) health survey conducted 2/17/21 through 2/22/21 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 2/22/21.
The sample was comprised of 2 current residents and 1 discharged resident. The facility had a census of 59 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 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 complaint (Intake #27828) health survey conducted on 3/17/21 are documented in this report. The facility was found to be in substantial compliance with OAR 411 - 85 through 89.
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OAR 411-085-0310 Residents' Rights: Generally
Refer to F558
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OAR 411-085-0360 Abuse
Refer to F609 and F610
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