Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 01/24/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:
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
MCCMemory 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
Based on interview and record review it was confirmed the facility failed to visually observe resident take medication. Findings include:
During an interview on 01/24/2023, Staff #1 (S1) stated they were aware of the medication error. The facility conducted a retraining with Staff #2 (S2) and a corrective action form was filed.
A review of a corrective action form filed for Staff #2 and the facilities policy and procedures for medication errors. CS identified that on 03/18/2022 the corrective action form states the description of the incident or policy violation was due to not watching residents take their medication.
On 01/24/2023, these findings were reviewed and acknowledged by S1.
Plan of Correction: The facility documented the incident, conducted an in-service, and followed up per their policy and procedure. Training was provided to staff member, although staff member was pulled off the floor and terminated for multiple infractions regarding medication errors.
Based on interview and record review it was confirmed that the facility failed to carry out medication orders as prescribed. Findings include:
During an interview on 01/24/2023, Staff #1 (S1) stated they were aware of the medication error. The facility conducted a retraining with Staff #2 (S2) and a corrective action form was filed.
A review of Resident #1 (R1) medication administration records (MARs) and progress notes for September 2022 as well as the facilities policy and procedures for medication errors. CS identified that on 09/09/2022 R1 missed a dose of medication X. The med error was followed up by alert charting and a corrective action form for Staff #2.
On 01/24/2023, these findings were reviewed and acknowledged by S1.
Plan of Correction: The facility documented the incident, conducted an in-service, and followed up per their policy and procedure. Training was provided to staff member, although staff member was pulled off the floor and terminated for multiple infractions regarding medication errors.