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 02/24/2023. 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 carry out medications as prescribed. Findings include:
During separate interviews on 02/24/2023, Staff #1-2 (S1 and S2) were aware of the medication error. The facility proceeded to investigate, notify physicians, obtain new written orders as needed, notified local adult protective services, and conducted and in-service and retraining to med tech.
A review of Resident #1 (R1) medication administration records (MARs) for February 2023, progress notes for 01/24/2023-02/24/2023 as well as the facilities policy and procedures for medication errors. CS identified that on 02/05/2023 R1 was not given medication X due to staff error. A same day incident report and proper notifications were made. The medication error was followed by alert charting for R1.
On 02/24/2023, these findings were reviewed and acknowledged by S1.
Plan of Correction: The facility documented the incident, filled out a med error report and followed up per their policy and procedure. Training was provided to med tech.
Based on interview, observation, and record review it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include:
During an interview on 02/24/2023, Staff #1 (S1) stated that their current staffing levels are 2 Med Tech (MT) and 3 Caregivers (CG) for day and swing shift and 1 MT and 1 CG for NOC shift. S1 was unable to express how they use their Acuity Based Staffing Tool (ABST) to generate their current staffing levels based on the amount of caregiving time indicated in the tool.
During an unannounced site visit on 02/24/2023, Compliance Specialist (CS) observed 2 MT and 3 CG working.
A review of the posted staffing plan and the facility ' s ABST. The ABST tool has inaccurate numbers stating that on day shift the facility needs 70.51 hours of care resulting in 9 CG needed. For swing 64.08 hours with 8.5 CG needed and NOC with 26.68 hours with 3.5 CG needed.
On 02/24/2023, these findings were reviewed and acknowledged by S1.