The findings of the initial survey conducted 12/15/20 through 12/17/20 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 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 initial survey of 12/17/20, conducted 3/10/21, 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 and Home and Community Based Services Regulations OARs 411 Division 004.
2. Resident 5 was admitted to the facility in March 2020 with diagnoses including dementia.
Review of the resident's progress notes, incident investigations and physician communications for 9/1/20 through 12/15/20 showed the following:
* On 10/7/20 it was noted the resident's PRN Oxycodone was given outside physician orders directing bedtime administration only, the medication was given at all times of the day and evening if/when requested. The supply of medication was depleted faster than planned and the pharmacy would not refill the medication because it was too soon. The medication error was investigated but there was no documentation to reflect the response of the staff at the time of the event and follow-up action by staff;
* The resident's spouse reported s/he gave 325 mg of Tylenol to the resident on 10/12/20. There was no documentation the incident was investigated;
* The resident was found on the floor on 10/12/20 having a panic attack, the resident was found to have reddened knees but no other injuries. The incident was not thoroughly investigated in a timely manner including follow-up action by staff to the event and administrator review to rule out abuse and neglect; and
* The resident slipped out of bed and was found on the floor on 12/2/20, no injuries were noted. The incident was not thoroughly investigated in a timely manner, including follow-up action by staff to the event and administrator review to rule out abuse and neglect.
The need to complete a thorough investigation including follow-up action by staff to rule out abuse and neglect was discussed with Staff 1 (Administrator), Staff 2 (Unit Manager/RN) and Staff 3 (RCC) on 12/16/20. The staff acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure investigations of all incidents were thorough and complete, reviewed by the administrator and all incidents of suspected abuse or neglect and injuries of unknown cause were reported to the local SPD office in a timely manner for 2 of 2 sampled residents (#s 1 and 5). Findings include, but are not limited to:
1. Resident 1 was admitted to the facility in September 2019 with diagnoses including atrial fibrillation.
a. An investigation report dated 9/16/20 indicated the resident had a 12 cm x 1 cm scratch on his/her left hip that could have been from "brief scratching during removal... too small or from a nail scratch." The resident, who had memory impairments, was not interviewed for the report. There was no documented evidence abuse and neglect had reasonably been ruled out, that the injury of unknown cause had been reported to the local SPD office or that the investigation had been reviewed by the administrator.
b. An investigation report dated 10/2/20 following a fall indicated staff discovered "scattered bruising on body at various stages of healing." There was no documented evidence of the bruises prior to the investigation, no subsequent investigation and/or report of the injury of unknown cause to the local SPD office and no administrator review of the investigation report.
c. An investigation report dated 11/7/20 indicated Resident 1 had a fall with injuries which included hematomas to left calf and left cheek. The resident was unable to inform staff how she fell. There was no documented evidence the investigation reasonably ruled out abuse and neglect, was reviewed by the administrator or that the injuries of unknown cause had been reported to the local SPD office.
d. An investigation report dated 12/1/20 following a fall indicated "three small scratches that appeared old were on the resident's right buttock." There was no documented evidence the facility had investigated the injury of unknown cause prior to or subsequent to their discovery on 12/1/20, no evidence the scratches had been reported to the local SPD office and no evidence the administrator had reviewed the investigation.
e. A progress note dated 12/2/20 stated Resident 1 had bruising and edema on his/her left foot. There was no documented evidence the facility investigated the injury of unknown cause to rule out abuse and neglect or notified the local SPD.
The need to thoroughly investigate incidents of suspected abuse and/or neglect and injuries of unknown cause in a timely manner and the need to report to SPD if unable to reasonably rule out abuse and neglect was discussed with Staff 1 (Administrator), Staff 2 (Unit Manager/RN) and Staff 3 (RCC). They acknowledged the findings.
Staff 1 was asked to report the incidents to the local SPD office and provided confirmation of the reports prior to survey exit.
1. What actions will be taken to correct the rule violation?
o Nurse Manager reviewed facility policy and procedure with resident #5's spouse explaining administering medications to spouse is prohibited and to notify care staff if pain relief is needed. This has been added to both residents' service plans.
o An initial investigation has been updated by the administrator regarding staff response and follow up action taken when medical orders were not followed for administering a schedule 2 medication for Res #5. The prescribing provider has also been notified.
o Resident #1 Service Plan has been updated and revised to include resident care givers to report any skin bruising, breaks, scratches, or swelling, observed during assistance with activities of daily living such as morning and evening personal care.
o Policy and procedure for Abuse Reporting has been revised and updated. All care staff are scheduled for training to review policies, procedures including how and when to follow up facility investigation and reporting to APS for injuries of unknown cause. (Training will be conducted by nurse consultant via zoom.)
2. How will the system be corrected so this violation will not happen again?
o The following procedure will be followed: Staff will notify the charge nurse on the same shift for any resident who has sustained an injury, bruises, skin breaks or scratches; the charge nurse will conduct a nursing assessment that includes whether or not the resident is able to identify what happened and take a report from any witness to the injury. Documentation will include (a) witness(es) and resident statements; and ( b) whether or not the service plan was being followed/and or needs to be updated; and (c ) whether or not the nurse was able to conclude by reasoned explanation with a nursing assessment that abuse or neglect did or did not occur. In the event that a well-documented explanation determines abuse/neglect did not occur and can be ruled out, the incident is not reportable to APS. If no credible or known explanation for the injury of unknown origin can be determined, the incident will be reported to APS within 24 hours of occurrence.
o Each shift handoff report will include information about residents' signs of injury and falls. Nurse Manager or Charge nurse concludes a facility investigation of any potentially contributing factors and makes a report to Adult Protective Services within 24 hours if abuse and neglect cannot be ruled out.
3. How often will the area needing correction be evaluated?
o Resident care staff will fill out a Stop and Watch for every resident at the time signs or symptoms of a potential injury occurs, including when new skin breaks or bruises are observed. Charge nurse will follow up with nursing assessment within 8 hours of report. Charge nurse will monitor process daily with reports provided in standup. Nurse manager will review all documentation and reports to APS.
4. Who has been assigned to evaluate the efforts? See # 3 above.
5. Who on your staff will be responsible to ensure that all the corrections are completed and monitored? Administrator.
Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and provided clear direction to staff for 2 of 2 sampled residents (#s 1 and 5) whose service plans were reviewed. Findings include, but are not limited to:
1. Residents 5's service plan dated 12/9/20 was not reflective of the resident's current status and lacked clear direction to staff in the following areas:
* Falls;
* Wanderguard use;
* Behaviors/angry outbursts;
* Dressing;
* Arm fracture; and
* Cast placement and care.
The need to ensure all resident service plans were reflective and provided directions to staff was discussed on 12/16/20 with Staff 1 (Administrator), Staff 2 (Unit Manager/RN) and 3 (RCC). The staff acknowledged the findings.
2. Residents 1's service plan dated 10/29/2020 was not reflective of the resident's current status and lacked clear direction to staff in the following areas:
* Wheelchair mobility;
* Behaviors during personal care;
* Afternoon naps;
* Groin rash;
* Incontinence;
* Discontinued use of recliner; and
* Use of hospital bed.
The need to ensure all resident service plans were reflective and provided directions to staff was discussed on 12/16/20 with Staff 1 (Administrator), Staff 2 (Unit Manager/RN) and 3 (RCC). The staff acknowledged the findings.
1. What actions will be taken to correct the rule violation?
o Residents #1 and #5 service plans have been updated with specific information regarding staff instructions on how to provide services to help ensure comfort, safety, personal and skin care, based on additional nursing assessments completed for both resident.
o Service plan changes include care giver weekly checks for wander guard for placement and testing for operation.
2. How will the system be corrected so this violation will not happen again?
o In addition to reading resident's service plan before providing care, each care staff member will complete weekly audits on a different resident's service plan weekly and note any changes, deletions or additions to resident's care/services to Nurse Manager.
3. How often will the area needing correction be evaluated?
o Weekly
4. Who has been assigned to evaluate the efforts?
o Nurse Manager
5. Who on your staff will be responsible to ensure that all the corrections are completed and monitored?
o Administrator
Based on interview and record review, it was determined the facility failed to determine and document what action or intervention was needed for the resident and failed to monitor changes of condition and document on the progress of the condition at least weekly until resolved, for 1 of 2 sampled residents (# 1) who experienced changes of condition requiring monitoring. Findings include, but are not limited to:
Resident 1 was admitted to the facility in September 2019 with diagnoses including atrial fibrillation.
The resident's 10/29/20 service plan and 9/1/20 through 12/15/20 progress notes were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution and/or lacked resident specific directions to staff in the following areas:
* Bruising;
* Edema;
* Groin rash;
* Symptoms of UTI;
* Scratches on buttocks; and
* Fall from the wheelchair.
The need to ensure short term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear resident specific directions to staff was discussed on 12/17/20 with Staff 1 (Administrator), Staff 2 (Unit Manager/RN) and Staff 3 (RCC). The staff acknowledged the findings.
1. What actions will be taken to correct the rule violation?
o Resident 1 evaluation and services plan reviewed and updated. Progress note updated with late entries include resolution of short term changes of condition.
o Policy and procedure to be reviewed, revised, updated and used to train nurses and med-techs on Alert Charting and 24 hour report.
2. How will the system be corrected so this violation will not happen again?
o 24 hour alert monitoring and charting list will be kept by med tech staff in med room and reviewed daily by Charge nurse. Care staff will update nurse for resident current status regarding need for monitoring past 72 hours. Nurse will keep track of and document all resolution of short term changes of condition. Nurse and med tech staff will review monitoring status of resident's short term change of condition in hand off shift reports.
o Each resident placed on monitoring for a short tem change of condition will have documentation reviewed by nurse and a specific, signed and dated note indicating condition has been resolved.
3. How often will the area needing correction be evaluated? Daily.
4. Who has been assigned to evaluate the efforts? Shift nurse, unit manager and med-techs.
5. Who on your staff will be responsible to ensure that all the corrections are completed and monitored? Administrator.
Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (# 5) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to:
Resident 5 was admitted to the facility in March 2020 with diagnoses including Alzheimer's disease.
Resident 5's signed physician orders dated 9/24/20 included the following orders:
* Oxycodone 2.5 mg at bedtime PRN for pain.
Resident 5's Controlled Substance Disposition logs and MARS, reviewed from 11/1/20-12/15/20 showed the following:
* A 12/5/20 dose of Oxycodone at 5:00 am was reflected on the disposition log but not on the MAR; and
* A 12/6/20 dose of Oxycodone at midnight was reflected on the MAR but not on the disposition log.
Comparison of the medication dosing card to the disposition log, showed the amount of medication left was reflected accurately on the log.
The need to ensure an accurate narcotic disposition log was maintained for all controlled substances was discussed with Staff 1 (Administrator), Staff 2 (Unit Manager/RN) and Staff 3 (RCC). The staff reviewed the documentation and acknowledged the findings.
1. What actions will be taken to correct the rule violation?
o Documentation on MAR and control drug log has been updated and completed for Res # 5. Med tech staff member responsible for this error has been terminated.
2. How will the system be corrected so this violation will not happen again?
o Policy and procedure for documentation of medication administration will be reviewed with all medication staff.
o Controlled drug count policy and procedures will be updated, and reviewed with all medication staff. Policy and procedure for control drug counts will be included. When drug counts are off or not able to be reconciled, the charge nurse will be notified without delay. Documentation of weekly audits of MARS and control drug will be completed for 4 weeks then monthly.
3. How often will the area needing correction be evaluated? S
o See #4.
4. Who has been assigned to evaluate the efforts?
o Nurse Manager.
5. Who on your staff will be responsible to ensure that all the corrections are completed and monitored? Administrator.
Based on interview and record review, it was determined the facility failed to ensure physicians orders were carried out as prescribed for 2 of 2 sampled residents (#s 1 and 5) whose orders were reviewed. Findings include, but are not limited to:
1. Resident 5 was admitted to the facility in March 2020 with diagnoses including Alzheimer's disease.
Review of the resident's 9/24/20 signed physician orders, 9/1/20 through 12/15/20 progress notes, physician faxes and 11/1/20 through 12/15/20 MARs showed the following medications were not administered as ordered by the physician:
* 11/5/20 morning medications including Calcium Carbonate (supplement), Vitamin D, Sertraline (antidepressant), Aspirin, Levothyroxine (thyroid medication) and Fosamax (bone health medication) were signed as given between 8:00 and 9:00 am. An exception note indicated the medications were given in the afternoon, approximately 3:00 pm.
Physician's orders indicated Levothyroxine was ordered for the morning and Calcium Carbonate was ordered twice a day. The remaining medications were ordered as once daily.
There was no indication the nurse or physician was consulted before medications were given late.
* Oxycodone 2.5 mg PRN at bedtime for pain was administered on 11/7/20, 11/9/20, 11/19/20 and 12/5/20 between the hours of 1:30 am and 6:00 am rather than bedtime as ordered.
The need to ensure all medications and treatments were administered as ordered was discussed with Staff 1 (Administrator), Staff 2 (Unit Manager/RN) and Staff 3 (RCC) on 11/16/20. The staff acknowledged the findings.
2. Resident 1 was admitted to the facility in September 2019 with diagnoses including atrial fibrillation.
Review of Resident 1's 11/1/20 through 12/15/20 MARs, 10/27/20 prescriber orders and interdisciplinary notes revealed the following:
Instructions on the MAR indicated medications were to be administered crushed in applesauce or pudding. On 12/16/20, Staff 8 (LPN) and Staff 2 (Unit Manager/RN) confirmed all medications were administered crushed. There was no documented evidence the facility had a signed prescriber order to crush medications.
The need to ensure medications were administered as prescribed was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 (RCC) on 12/16/20. They acknowledged the findings.
1. What actions will be taken to correct the rule violation?
o An investigation has been completed regarding late medications for Res #5. Med tech employment has been terminated
o Facility policies for daily and multiple medication administration times are under review and consideration for adjustments to medication administration times and to meet resident's preferences unless a medical order/pharmacist instructions otherwise indicates a specific time.
o Breakfast: anytime between 8-10 a.m.
o Lunch: anytime between 11:30 a.m. to 1:30 p.m.
o Dinner; anytime between 4:30- 6:30 p.m.
o Bedtime: anytime between 8:00-11: pm.
2. How will the system be corrected so this violation will not happen again?
o A pharmacy approved list will be reviewed by med tech before crushing any medication along with obtaining a signed medical order for each medication to be crushed.
o All med-tech staff will complete Oregon Care Partners 3 hour Role of the Med Tech and obtain certificate of completion.
3. How often will the area needing correction be evaluated?
o Licensed nurses will conduct random observational audit/checks weekly for med techs following policies and procedures while preparing med passes.
4. Who has been assigned to evaluate the efforts?
o Charge nurses.
5. Who on your staff will be responsible to ensure that all the corrections are completed
and monitored?
o Nurse Managers and Administrator.
Based on interview and record review, it was determined the facility failed to ensure MARs were complete and accurate, contained medication specific instructions and reflected resident specific parameters for PRN medications for 2 of 2 sampled residents (#s 1 and 5) whose MARs were reviewed. Findings include, but are not limited to:
1. Resident 5 was admitted to the facility in March 2020 with diagnoses including Alzheimer's disease.
Review of the resident's 11/1/20 through 12/15/20 MAR and 9/24/20 physician orders were reviewed and showed the following:
* The November and December MAR contained orders for PRN Tylenol for pain and PRN Oxycodone for pain with no instructions on which medication to use first;
* Effectiveness of PRN pain medications was inconsistently documented on numerous occasions; and
* Potential significant side effects for medications was not reflected for all medications.
The need to ensure MARs were complete and accurate was discussed on 12/16/20 with Staff 1 (Administrator), Staff 2 (Unit Manager/RN) and Staff 3 (RCC). The staff acknowledged the findings.
2. Resident 1 was admitted to the facility in September 2019 with diagnoses including atrial fibrillation.
Review of the resident's 11/1/20 through 12/15/20 MAR and 10/27/20 physician orders were reviewed and showed the following:
* Potential significant side effects for medications was not reflected for all medications;
* Multiple PRN bowel care medications lacked clear direction and instruction to staff regarding administration; and
* Multiple blanks on the MAR.
The need to ensure MARs were complete, accurate and provided clear instruction to staff was discussed on 12/16/20 with Staff 1 (Administrator), Staff 2 (Unit Manager/RN) and Staff 3 (RCC). The staff acknowledged the findings.
1. What actions will be taken to correct the rule violation?
o Res #1 and #5 duplicate medication orders for pain and bowel care now have specific parameters regarding which medication to give first and instructions to staff.
2. How will the system be corrected so this violation will not happen again?
o All medications based on PRN will have specific parameters written by the nurse.
o All prn medication given will also have results documented on the same shift and or included in shift hand off report for next shift to observe and document.
3. How often will the area needing correction be evaluated.
o Weekly MAR audits by shift nurse or unit manager.
4. Who has been assigned to evaluate the efforts?
5. Nurse Manager
Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed thoroughly by an RN, PT or OT prior to use for 1 of 1 sampled resident (# 1) who had a side rail on their bed. Findings include, but are not limited to:
Resident 1 was admitted to the facility in September 2019 with diagnoses including arthritis.
During an observation on 12/5/20, Resident 1's hospital bed was observed to have side rails on both sides of the bed.
There was no documented evidence a side rail assessment had been completed by an RN, PT or OT which included:
*Informing the resident of the risks and benefits associated with the device;
*The facility documented other less restrictive alternatives evaluated prior to the use of the device;
*The facility had instructed caregivers on the correct use and precautions related to the use of the device; and
*Documenting the use of the side rail on the service plan.
The need to ensure supportive devices with potentially restraining qualities were assessed prior to use was discussed with Staff 1 (Administrator), Staff 2 (Unit Manager/RN) and 3 (RCC). They acknowledged the findings.
1. What actions will be taken to correct the rule violation?
o Resident #1 has been evaluated for safety in use of side rails. Documentation for the evaluation is located in the chart.
o Service Plan has been updated with specific instructions related to safety checks and specific and limited use of the side rails.
2. How will the system be corrected so this violation will not happen again?
o A policy and procedure has been developed and reviewed by nurse managers, and includes risks/benefits explained to resident; less restrictive alternatives will be used and evaluated prior to use of more restricted devices and all care staff will be trained to follow use and safety precautions as stipulated on the resident's service plan.
3. How often will the area needing correction be evaluated?
o A quarterly assessment will be completed by RN, OT or PT to determine continued need and safe use and will be included in the resident's service plan.
4. Who has been assigned to evaluate the efforts?
o Charge nurses.
5. Who on your staff will be responsible to ensure that all the corrections are completed and monitored?
o Nurse Manager and administrator.
Based on interview and record review, it was determined the facility failed to ensure all requirements were met for Fire and Life Safety preparedness, instruction and documentation. Findings include, but are not limited to:
On 12/15/20 review of facility records and interviews with staff indicated the following deficiencies:
* During interviews on 12/15/20, 2 of 2 Staff 7 (MT) and Staff 10 (CG) were unable to identify the designated point of safety for an emergency evacuation from the building.
* There was no documented evidence that residents received instruction on fire and life safety procedures within 24 hours of admission.
* There was no documented evidence of a system to identify residents who were unable or unwilling to participate in fire drills, and to show immediate changes were made to ensure the evacuation standard was being met.
On 12/15/20 the need to ensure all requirements were met for Fire and Life Safety preparedness, instruction and documentation was discussed with Staff 1 (Administrator) and Staff 4 (Maintenance Manager). They acknowledged the findings.
1. What actions will be taken to correct the rule violation?
o All staff have been trained on evacuation procedures and locations.
o Within 24 hours of move in, all residents will receive written instructions with verbal review by administrator or designee for fire and life safety emergency procedures. The resident and administrator (designee) will sign and date this information and will be kept in the resident's record.
o When resident declines to participate in fire drills, a written and verbal review with the resident will be completed by administrator or designee.
2. How will the system be corrected so this violation will not happen again? Move in paperwork will include this procedure with signatures and dates; refusal or decline to participate will be reflected on the initial service plan and every 90 day service plan afterwards.
3. How often will the area needing correction be evaluated
o Every 90 days with review and updates to each resident's service plan.
4. Who has been assigned to evaluate the efforts? Administrator or designee.
5. Who on your staff will be responsible to ensure that all the corrections are completed and monitored? Administrator or designee.
C 290 - Resident Health Services: On- and Off-Site Health Services
OAR 411-054-0045(2)
(2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers.
When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information,
for residents whose health status is stable and predictable.
(a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental
health care providers, etc.
(A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place.
(B) The facility nurse must review the resident's health related
service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule.
(C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident
and any clinical information necessary for facility staff to provide supplemental care.
C 305 Resident Right to Refuse
OAR 411-054-0055(1)(i)
(j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.
(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber.
C 372 - Training within 30 days: Direct Care Staff
OAR 411-054-0070 (5)(8)
Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training.
(5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF.
(a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned.
(b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to:
(A) The role of service plans in providing individualized resident care.
(B) Providing assistance with the activities of daily living.
(C) Changes associated with normal aging.
(D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition.
(E) Conditions that require assessment, treatment, observation and reporting.
(F) General food safety, serving and sanitation.
(G) If the direct care staff person's duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications
and Treatments) must document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised.
C 655 - Call System
OAR 411-054-0300 (11-13)
(b) EXIT DOOR ALARMS. Exit door alarms or other acceptable systems must be provided for security purposes and to alert staff when residents exit the ALF. The door alarm system may be integrated with the call system.
C 305:
The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber.
