The findings of the complaint (Intake# 24578) health survey conducted 1/11/21 through 1/14/21 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 1 closed record.
The facility had a census of 58 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 #24578) health survey conducted 3/5/21 through 3/15/21 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 interview and record review, it was determined the facility failed to protect a resident's right to refuse treatment for 1 of 1 sampled resident (#1) reviewed for sexual abuse. This placed residents at risk for healthcare decisions to be in conflict with resident's wishes. Findings include:
Resident 1 was admitted to the facility in 4/2020 with diagnoses including PTSD (post-traumatic stress disorder) and anxiety disorder.
A 4/23/20 care plan revealed Resident 1 was sexually abused during childhood and had PTSD. The goal was to recognize her/his triggers and how to cope with each day. Interventions included to allow Resident 1 time for requests and allow time for Resident 1 to communicate her/his needs. Do not interrupt or speak over Resident 1 and actively listen to her/his requests.
A 5/2020 TAR instructed staff to apply Nystatin (antifungal) cream to Resident 1's buttocks and groin area three times a day for skin impairment. On 5/1/20 Staff 3 (RN) documented completing treatment on day shift.
A 5/6/20 Facility Investigation revealed Resident 1's treatment included a rash to her/his groin with a physician ordered for Nystatin cream to be applied three times a day. On 5/1/20 Staff 3 applied Nystatin cream to Resident 1 as ordered. Staff 3 stated Resident 1 was "jumpy" and agitated during the treatment, however did not tell Staff 3 to stop. Abuse and neglect was not substantiated.
A 5/6/20 Incident/Investigation Report by the police department revealed when Staff 3 was applying Nystatin cream to Resident 1's groin area Resident 1 asked Staff 3 to stop treatment and Staff 3 ignored Resident 1 and continued to apply the cream.
On 1/12/21 at 2:27 PM Resident 1 stated on 5/1/20 she/he told Staff 3 she/he did not want Nystatin cream applied to her/his groin area. Resident 1 stated during the procedure Resident 1 again asked for Staff 3 to stop and Staff 3 continued to apply the Nystatin cream. Resident 1 stated Staff 3 focused on the task and did not listen to Resident 1.
On 1/13/21 at 9:14 AM Staff 11 (Physical Therapist Assistant) stated on 5/6/20 Resident 1 was distressed and stated she/he felt violated by Staff 3. On 5/1/20 Resident 1 did not want Nystatin cream applied to her/his groin area by Staff 3 and he still applied the cream. Resident 1 stated this caused her/him to be triggered from past trauma from her/his childhood.
On 1/13/21 at 1:36 PM Staff 3 stated on 5/1/20 Resident 1 did not refuse the treatment initially. Part way through with applying the cream Resident 1 was acting like it was painful and asked for Staff 3 to stop. Staff 3 asked if he could complete the treatment to help to continue with the healing of Resident 1's skin. Staff 3 stated he thought he received an "indication" from Resident 1 to go ahead and complete the treatment.
On 1/14/21 at 11:00 AM Staff 1 (Administrator) and Staff 2 (DNS) stated Staff 3 may have not been aware of Resident 1's past trauma trigger points.
There was only one resident identified, ( Resident # 1 per the 2567), to have been affected by the deficient practice. This resident discharged 6/18/2020 and is no longer in the facility.Social Services will conduct an audit on 100% of our population to determine if any other residents are impacted. Corrective Action, if other residents are identified, will include further education and care plan modification.Education was provided 2-1-2021 to all staff regarding resident’s right to request, refuse, decline treatment and Trauma Informed Care. Post-quiz will determine understanding of material. Follow up education will be provided to any staff who demonstrate lack of understanding. LN’s and RCM’s will follow up to ensure Plans of Care reflect resident choices. Education will be provided to new staff regarding resident rights.DNS, or designee, to complete audits to ensure resident’s rights to request/refuse and/or discontinue treatment are being honored, will be completed weekly x 4 weeks, Monthly for 3 months to ensure ongoing compliance. Any adverse findings will be reported to the facility QAA committee.
The findings of the licensure and complaint (Intake # 24578) health survey conducted 1/11/21 through 1/14/21 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 1/14/21.
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 complaint (Intake #24578) health survey conducted 3/5/21 through 3/15/21 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 Resident Rights: Generally [Right to Refuse Care.]
Refer to F578
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