Based on interview and record review it was determined the facility failed to notify the State Survey Agency of resident elopements for 1 of 1 sampled resident (#1) reviewed for elopement. This placed residents at risk for elopement. Findings include:
Resident 1 admitted to the facility in 2019 with diagnoses including alcoholic cirrhosis of the liver.
A review of Resident 1's clinical record indicated elopements from the facility on 7/26/20, 9/7/20, 10/12/20, 10/17/20, 10/19/20 and 10/21/20.
There was no indication the elopements were reported to the State Survey Agency for the identified dates.
On 10/23/20 at 11:10 AM Staff 1 (Administrator) confirmed the elopement investigations were not submitted to the State Survey Agency for the identified dates.
Based on interview and record review it was determined the facility failed to ensure supervision, treatment and services were in place to prevent elopement for 1 of 1 sampled resident (#1) reviewed for elopement. This placed residents at risk for accidents. Findings include:
Resident 1 admitted to the facility in 2019 with diagnoses including alcoholic cirrhosis of the liver.
A review of Resident 1's clinical record indicated elopements from the facility on 7/26/20, 9/7/20, 10/12/20, 10/17/20, 10/19/20 and 10/21/20.
The facility's 8/2014 Code Pink Protocol indicated if a resident was found outside the facility a risk management assessment was to be completed, the resident was to be placed on alert monitoring, preventative measures were to be placed and the care plan was to be updated.
The 1/10/20, 7/12/20 and 10/12/20 MDS Section C indicated Resident 1 had a BIMS between 13 and 15 indicating the resident was cognitively intact.
A 1/4/20 Elopement investigation indicated Resident 1 left the facility without notifying staff. The resident returned to the facility and reported she/he went to the store. The resident had no prior elopement attempts.
The care plan was updated on 1/4/20 and indicated Resident 1 was at risk for elopement due to alcohol seeking behaviors. The interventions included determining reasons for wanting to leave and a Code Pink Protocol was implemented.
A 7/26/20 progress note indicated Resident 1 left the facility without alerting staff. The resident was found by staff sitting at the bus stop and stated she/he wanted to go to the store. The resident returned to the facility.
A risk management assessment was not completed, there were no updates to the care plan and there was no indication alert charting was completed. An elopement investigation was not completed.
A 9/7/20 progress note indicated Resident 1 "escaped" to the store across the street. Staff found the resident and she/he returned to the facility.
A risk management assessment was completed 11 days later on 9/18/20 and an elopement investigation was not completed.
The care plan was also updated 11 days later on 9/18/20 to include to the monitor resident's whereabouts and notify nurse if she/he wanted to leave. The resident was to not drink any alcohol per physician due to liver disease. The care plan further indicated, "Do not let the resident out of the facility at all at this time."
A 10/12/20 progress note indicated Resident 1 was found outside the facility drinking alcohol. The resident returned to the facility.
A risk management assessment nor an elopement investigation were not completed and there were no updates to the care plan.
A 10/17/20 elopement investigation indicated Resident 1 was found on the sidewalk drinking alcohol outside the facility. Resident 1 deactivated the door alarm. The resident returned to the facility.
The resident's care plan was updated on 10/17/20 to include 30 minute checks.
A 10/19/20 progress note indicated Resident 1 was not in her/his room. Staff noticed the exit door was slightly open and the alarm was deactivated. Staff went outside and observed Resident 1 walking toward the street. Staff were able to redirect Resident 1 back to the facility.
The 10/19/20 elopement investigation indicated Staff 4 (CNA) witnessed the resident pacing the halls and while the staff was helping out another resident the nurse informed Staff 4 the resident opened the side door. Staff 4 further indicated she was the only CNA on the floor and could not watch Resident 1 and perform CNA duties at the same time. The investigation report indicated interventions included to continue 30 minute checks and a new alarm was ordered that could not be turned off by the resident.
A 10/21/20 progress note indicated Resident 1 exited the facility and was found by staff at the store and the resident had unopened alcohol. The resident returned to the facility with staff.
The resident's care plan was updated to include elopements that occurred on 10/12/20, 10/17/20, 10/19/20 and 10/21/20. New interventions included to give medications as ordered by the physician.
The facility 30 minute checks documentation indicated Resident 1's 30 minute checks started on 10/16/20, not 10/17/20 as indicated in the 10/17/20 care plan update.
On 10/21/20 at 3:25 PM Staff 4 stated on 10/19/20 she was the only CNA working on the south hall for night shift. She stated Resident 1 was on 30 minute checks due to alcohol seeking and attempts to elope. Staff 4 stated she was unable to monitor Resident 1 and the resident exited the facility when she was busy assisting another resident. She stated Resident 1 knows what she/he is doing and is aware when staff were not in the halls.
On 10/22/20 at 3:30 PM Staff 5 (LPN) stated on 10/19/20 the facility was short staffed and there was only one CNA in the south hall and she was the only nurse on south hall. She stated she was in a room providing medication to a resident and when she came out of the room she noticed Resident 1 was not in the hall and the exit door was open. She was able to redirect Resident 1 back to the facility. She also stated she was unable to monitor the resident appropriately due to being short staffed, and Resident 1 was cognitively intact.
On 10/23/20 at 11:10 AM Staff 1 (Administrator) and Staff 3 (Corporate Nurse) confirmed the lack of complete elopement investigations and the lack of elopement risk assessments.
On 10/28/20 at 10:07 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the care plan was not followed related to monitoring Resident 1 and the care plan was not updated timely. Staff 1 and Staff 2 further acknowledged on 10/19/20 Resident 1 eloped and there was not adequate staff to ensure her/his care plan was followed.
Based on interview and record review it was determined the facility failed to ensure residents were free from unnecessary psychotropic medication for 1 of 1 sampled residents (#1) reviewed for elopement. This placed residents at risk for adverse side effects. Findings include:
Resident 1 admitted to the facility in 2019 with diagnoses including alcoholic cirrhosis of the liver.
A review of the progress notes indicated Resident 1 had a history of elopement and alcohol seeking behaviors. The resident eloped on on 1/4/20, 7/26/20, 9/7/20, 10/12/20, 10/17/20, 10/19/20 and 10/21/20.
The 10/8/20 physician progress note indicated Resident 1 had a history of alcohol abuse. The progress note indicated Resident 1 had no increased nervousness or depression.
The 10/21/20 progress note indicated nursing staff spoke to Resident 1's physician regarding her/his behaviors and elopements. Orders were received for Depakote (mood stabilizer medication) and Vistaril (antianxiety medication) PRN for the resident's anxiety related to alcohol addiction. The provider indicated she would re-assess the resident to see what else could be done.
A 10/21/20 physician order indicated Resident 1 was to receive Depakote BID for restless behaviors related to alcohol addiction and Vistaril PRN for 14 days for anxiety related to alcohol addiction and pacing hallways.
The 10/20 MAR indicated Resident 1 received Depakote on occasion on 10/21/20 and refused it on 10/22/20. Resident 1 did not receive Vistaril.
A review of the progress notes indicated there was no follow up visit by the physician to assess Resident 1.
There was no clinical rationale provided by the physician for the use of Depakote and Vistaril.
A review of the medical record indicated Resident 1 did not have a diagnosis of anxiety or other mental health diagnoses.
On 10/28/20 at 10:13 AM Staff 2 (DNS) acknowledged there was no diagnoses or clinical rationale for the use of Depakote and Vistaril for Resident 1.
Based on interview and record review it was determined the facility failed to ensure records were complete and accurate for Direct Care Staff Daily Reports. This placed residents at risk for inaccurate staffing information. Findings include:
Direct Care Staff Daily Reports from 9/20/20 through 10/20/20 were compared to the facility daily staff schedule. There were 25 of 31 days when one or more shifts had discrepancies between the Direct Care Staff Daily Reports and the daily staff schedule.
On 10/20/20 at 11:10 AM Staff 1 (Administrator) acknowledged the discrepancies for the identified dates.
Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing ratios were maintained for 18 of 32 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 9/20/20 through 10/25/20 revealed 18 occasions when one or more shifts did not meet the minimum CNA staffing ratios.
On 10/22/20 at 11:10 AM Staff 1 (Administrator) acknowledged minimum CNA staffing ratios were not met on the identified dates.
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OAR 411-085-0360 Abuse
Refer to F609
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OAR 411-086-0140 Nursing Services: Problem Resolution & Preventative Care
Refer to F689 and F758
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OAR 411-085-0370 Confidentiality
Refer to F842
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