The findings of the initial survey conducted 1/5/21 through 1/7/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
CBG: capillary blood glucose or
blood sugar
cc: cubic centimeter
CG: caregiver
cm: centimeter
F: Fahrenheit
HH: Home Health
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MA: Medication Aide
MAR: Medication Administration
Record
MCC Memory Care Community
mg: milligram
ml: milliliter
O2 sats: oxygen saturation in the
blood
OT: Occupational Therapist
PT: Physical Therapist
PRN: as needed
qd: every day or daily
qid: four times a day
RN: Registered Nurse
SP: service plan
TAR: Treatment Administration
Record
tid: three times a day
The findings of the first re-visit to the re-licensure survey of 1/7/21, conducted on 4/22/21, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.
Based on interview and record review, it was determined the facility failed to provide reasonable precautions against conditions that could threaten the health, safety or welfare of residents. Findings include, but are not limited to:
Resident 3 was admitted to the facility November 2020 with diagnosis including Alzheimer's disease. Record review revealed the resident was allergic to two medications and Latex and had a physician order for an EpiPen injection, PRN for a severe allergic reaction.
Upon review of Resident 3's 11/4/20 service plan, there was no clear direction of what the resident could have an allergic reaction to, what signs or symptoms to monitor for and what to do in case of an allergic reaction. The resident's December 2020 and January 1 through 5, 2021 MARs were reviewed. There was no clear direction to unlicensed staff on what the EpiPen would be used for as the resident's allergies were listed as declomycin, erythromycin and Latex.
During a phone interview on 1/6/21 at 2:57 pm with Staff 2 (Generations Program Director) and with Staff 3 (RN), it was confirmed staff had not been trained on how to administer the EpiPen in the event of an emergency. Staff 2 also confirmed the EpiPen was ordered for a Latex allergy.
Staff 2 wrote instructions on how staff would need to respond if Resident 3 was exposed to Latex and implemented a Temporary Service Plan during the survey. Staff 3 stated training on the EpiPen would begin the evening of 1/7/21.
The need to ensure staff were trained on how to administer an EpiPen and had clear direction relating to the resident's allergies, what signs and symptoms to monitor for and what to do in case of a severe allergic reaction was discussed with Staff 1 (ED) and Staff 2. They acknowledged the findings.
OAR 411-054-0025 (4):
1. As of 01/12/2021, All Med aides have been trained on the administration of the EpiPen, what it would be used of, and allergic reactions to monitor for.
2. Going forward, the Registered Nurse will teach all med aides EpiPen administration procedures relating to the resident's allergies and what signs and symptoms to monitor for, prior to administering medications to the resident. An RN or trained staff will be on duty at all times when we have a resident that requires one.
3. Evaluation and training will be completed prior to move in or at change of condition.
4. The RN will be responsible for assessment, training. Administrator and RN will review during quarterly resident reviews.
Based on interview and record review, it was determined the facility failed to report resident incidents in a timely manner to the local Seniors and People with Disability (SPD) office for 1 of 1 sampled resident (# 2) who was reviewed with resident to resident altercations. Findings include, but are not limited to:
Resident 2 was admitted to the facility in December 2019 with diagnoses including Alzheimer's dementia with behavioral disturbance.
During the acuity interview on 1/5/21, Resident 2 was identified as having resident to resident altercations.
The Resident Incident Report dated 12/13/20 noted Resident 2 was "shoved on [his/her] shoulder." An interview with Staff 2 (Generations Program Manager) on 1/5/21 at 2:07 pm confirmed the incident had not been reported to the local SPD office.
The need to report incidents to the local SPD office if abuse and/or neglect could not be ruled out was discussed with Staff 1 (ED) and Staff 2. They acknowledged the findings.
Staff 2 was asked to report the incident on 1/5/21 to the local SPD office and provided confirmation of the report prior to survey exit.
OAR 411-054-0028 (1-3):
1. We self reported the incident on 1/5/2021.
2. All Med Techs, Care Givers, Generations Program Director and the RN were re-trained in Abuse reporting. All Med Techs and Caregivers will notify the Generations Program Director or the RN immediately upon being aware of a resident to resident altercation and will start the investigation process within 24 hours.
3. New hires will be trained on abuse reporting prior to working with residents. Abuse Reporting will be part of the annual training for all staff.
4. Generations Program Director and Executive Director will be responsible for monitoring the compliance with this regulation, auditing files annually to ensure all training has been completed and signed off.
Based on interview and record review, it was determined the facility failed to ensure quarterly and move-in evaluations addressed all required components for 2 of 2 sampled residents (#s 2 and 3) whose evaluations were reviewed. Findings include, but are not limited to:
1. Resident 2's quarterly evaluation dated 10/21/20 had conflicting information of the resident's provision of care, was not used as the foundation for the resident's service plan, and/or failed to address the following required components:
* Two hour safety checks at night;
* Depression;
* PRN suppository;
* Routine oral medications;
* Non-verbal signs of pain;
* Use of compression hose;
* Behaviors; and
* Environmental factors that impact the resident's behavior including, but not limited to noise, lighting, room temperature.
Review of Resident 2's service plan dated 10/21/20 showed conflicting information relating to two-hour safety checks at night, depression and the use of compression hose. Review of the resident's December 2020 and January 1 through 5, 2021 MARs verified incorrect information relating to the use of a PRN suppository and routine oral medications. An interview with Staff 13 (CG) on 1/6/21 confirmed interventions she used when the resident was not able to verbally express pain, was exhibiting behaviors and what environmental factors contributed to those behaviors.
2. Resident 3 was admitted to the facility in November 2020. The new move in evaluation failed to address the following required components:
* Personality including how the person copes with change or challenging situations;
* Non-drug interventions for pain, including how a person expresses pain or discomfort;
* Signs, symptoms and reasons for the use of an emergency EpiPen injection; and
* Environmental factors that impact the resident's behavior including, but are not limited to noise, lighting, room temperature.
The need to ensure evaluations included all required components was discussed with Staff 1 (ED) and Staff 2 (Generations Program Director) on 1/7/21. They acknowledged the findings.
OAR 411-054-0034
1.Resident #2's service plan was reviewed and compared to the initial assessment, ensureing all care needs are captured in the service plan. The following were added:
~Two- hour safety checks at night
~Depression
~PRN suppository
~Routine Oral medications
~Non-verbal signs of pain
~Use of compression hose
~Behavior; and
~Environmental factors that impact the resident's ~behavior including, but not limited to noise, lighting, ~room temperature.
1.Resident #3's service plan was reviewed and compared to the initial assessment, ensuring all care needs were captured in the service plan. The following were added:
~ Personality including how the person copes with change or challenging situations;
~ Non-drug interventions for pain, including how a person expresses pain or discomfort;
~Signs and symptoms and reasons for the use of an emergency EpiPen injection; and
~Environmental factors that impact the resident's behavior including but are not limited to noise, lighting, room temperature.
2. Evaluation process was changed to ensure all information transfers from the evaluation form to the service plan and all care needs are addressed and written in the service plans. An audit of all service plans will be completed by the date we are alleging compliance, comparing the evaluation to the service plan and ensuring all informaiton was captured on the service plan.
3. Service Plans will be reviewed and compared to the evaluations at move in, first 30 days and quarterly at the 90 day review period.
4. The Generations Program Director will be responsible for reviewing Service Plans at time of move in, first 30 days and quarterly at the 90 day review period.
Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 3 sampled residents (# 2) whose orders were reviewed. Findings include, but are not limited to:
Resident 2's December 2020 and January 1 through 5, 2021 MARs and current physician orders were reviewed and revealed the following:
a. Resident 2 had physician orders for daily weights and two PRN medications relating to edema. Per the signed orders, the facility was directed to contact the provider for a three pound or greater weight gain in one day. On 1/2/21, the MAR showed a weight gain in one day of 4.9 pounds. Resident 2 also had signed orders for a PRN potassium and a PRN torsemide to be administered for a weight gain of three pounds or greater in one day. An interview on 1/6/21 at 10:40 am with Staff 6 (MA) confirmed there was no documented evidence the physician was notified or that the medications were administered on 1/2/21 per physician orders.
b. Resident 2 had physician orders for three PRN bowel medications with parameters to administer Miralax for no bowel movement in one day, administer Milk of Magnesia if no bowel movement in 48 hours and to administer a Dulcolax suppository if the resident had not had a bowel movement in 72 hours. The Bowel Movement Log for January 2021 was reviewed. It reflected Resident 2 did not have a bowel movement in 24 hours by the morning of 1/3/21. There was no documented evidence the facility administered the Miralax per physician orders for not having a bowel movement in one day.
The need to ensure the facility followed physician orders was discussed with Staff 1 (ED) and Staff 2 (Generations Program Director) On 1/7/21. They acknowledged the findings.
OAR 411-154-0055
1. On 1/6/21, regarding Resident 2, Hospice was notified that two PRN medications had not been given as ordered due to increase in daily weight. Hospice discontinued daily wieghts and PRN medication on 1/9/21.
2. A system was created to alert the the Med Tech of weight changes when they enter new weights. They will be required to enter in the system if a PRN was needed or not.
3. Monthly MAR audits will be conducted by RN.
4. The RN will be resposnable for monthly MAR audits and checking weights.
1. Also regarding Resident 2, Hospice was notified on 1/6/21 that resident did not receive PRN order for Miralax as ordered for no bowel movment in 24hrs. Hospice discontinued PRN order on 1/6/21.
2. Order was placed on MAR for Med Techs to document checking the bowel log each shift and adminster PRN medications as ordered.
3. Monthly MAR audits.
4. RN
Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented every other month and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to:
Fire drill and fire and life safety records were reviewed from 1/22/20 to 1/5/21. The facility failed to to have documented evidence of the following:
*Escape route used;
*Residents who resisted or failed to participate in the drills;
*Evacuation time period needed; and
*Number of occupants evacuated.
There was no documented evidence the facility was providing fire and life safety instruction to staff on alternating months.
The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (ED), Staff 2 (Generations Program Director), and Staff 4 (Building Services Director). They acknowledged the facility was not providing fire and life safety instruction to staff and that the facility was not relocating or evacuating residents during fire drills.
OAR 411-054-0090 (1)(a-d):
1. We have scheduled a fire drill and training for staff and residents.
2. We have created a Fire, Life & Safety binder that will be used going forward to ensure we are meeting the requirements for fire drills and safety meetings.
3. The information gathered each month will be reviewed and signed off by the Generations Program director on a monthly basis. Fire drills and training will be properly documented and remain in the binder for a period of two years.
4. The Maintenance director will be responsible for ensuring all fire drills and training are completed in the appropriate month. The Generations Program Director will review the monthly documentation.
Based on interview and record review, it was determined the facility failed to ensure general fire and life safety training was provided to residents and staff. Findings include, but are not limited to:
Fire and life safety records dated 1/22/20 through 1/5/21, were reviewed on 1/5/21 and lacked the following components:
*Fire drills including staff evacuating the residents to a designated point of safety;
*A designated point of safety; and
*Record of annual training for residents on the facility's fire and life safety procedures.
The need to ensure the facility provided evacuation assistance to residents to a designated point of safety were, and that residents received training about the facility's fire and safety procedures annually was discussed with Staff 1 (ED), Staff 2 (Generations Program Director), and Staff 4 (Building Services Director) on 1/5/21. They acknowledged the findings.
OAR 411-054-0090 (1(e-h))-(2-5):
1. We have scheduled a fire drill and training for staff and residents.
2. We have created a Fire, Life & Safety binder that will be used going forward to ensure we are meeting the requirements for fire drills and safety meetings.
3. The information gathered each month will be reviewed and signed off by the Generations Program director on a monthly basis. Fire drills and training will be properly documented and remain in the binder for a period of two years.
4. The Maintenance director will be responsible for ensuring all fire drills and training are completed in the appropriate month. The Generations Program Director will review the monthly documentation.
C 330 - Systems: Psychotropic Medication
OAR 411-054-0055 (6)
(6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use. (a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning. (b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. (c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted. (d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:
(A) The specific reasons for the use of the psychotropic medication for that resident.
(B) The common side effects of the medications.
(C) When to contact a health professional regarding side effects.
(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's
primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by
telephone or electronic submission and should be documented by the facility. (f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.
(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.
(B) All direct care staff must have knowledge of non-pharmacological interventions.
(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility.
Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:
Refer to: C 160, C 231, C 420 and C 422.
OAR 411-057-0140(2): Administration Compliance
Please reference plan of correction for:
- C160
- C231
- C252
- C420
- C422
Based on interview and record review, it was determined the facility failed to ensure required memory care specific pre-service orientation was completed prior to beginning job duties and failed to ensure staff demonstrated competency in all required memory care specific training topics within 30 days of hire for 2 of 4 newly hired staff (#s 7 and 12). Findings include, but are not limited to:
Review of training records for newly hired Staff 7 (MT) and Staff 12 (CG), hired 3/25/20 and 10/1/20 respectively, lacked documented evidence the following training requirements had been completed:
Pre-service orientation:
*How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment.
Demonstrated competency within 30 days of hire:
*Identification, documentation, and reporting of changes of condition; and
*Conditions that require assessment, treatment, observation and reporting.
The failure of the facility to ensure required memory care specific pre-service orientation was completed prior to staff beginning job duties, that staff demonstrated competency in all required memory care specific training topics within 30 days of hire was discussed with Staff 1 (ED) and Staff 2 (Generations Program Director) on 1/7/21. No further documentation was provided.
OAR 411-057-0155: Staff Training Requirements
1. We scheduled training for change of condition with both staff members that were deficient in this area.
2. We updated our pre-service orientation checklist to include change of condition. Our registered nurse will be responsible for training all staff within 30 days of new hire.
3. Generations Program Director will monitor and sign off on all pre-service orientation checklists within 30 days of hire.
4. Generations Program director will be responsible for ensuring this is completed.
Based on interview and record review, it was determined the facility failed to ensure health care service were consistently provided. Findings include, but are not limited to:
Refer to C 252 and C 303.
OAR 411-057-0160(2b):
Please reference plan of correction for:
- C303
