Based on interview and record review, conducted during a site visit on 12/04/23, 12/05/23, 12/07/23, 12/08/23, and 12/11/23 it was confirmed the facility failed to properly investigate and immediately notify the local Department office of multiple instances in which abuse or suspected abuse could not be ruled out for 5 of 5 sampled residents (#s 4, 10, 20, 28 and 37).
1) During an interview on 12/04/23, Staff 9 (Activities, former RCC) stated the process for investigating and reporting incidents was as follows:
*Call for help;
*Assess for injuries and take vitals;
*Call the resident's family, alert the resident's physician;
*Notate incident in progress notes;
*Fill out an incident report and pass it off to the executive director (ED) to send to the state.
An incident report for Resident 4, dated 11/20/23, indicated Staff 9 (Activities) had witnessed another resident touching Resident 4 in a sexual manner. The local SPD office was not notified until 12/01/23. The facility self-report form was dated 11/13/23.
2) An incident report for Resident 10, dated 07/22/23, indicated s/he had experienced a witnessed fall resulting in pain in her right arm on 07/21/23. Witnesses were listed as "the community."
There was no indication the facility investigated the incident immediately and adequately to rule out abuse, nor was there an indication an Administrator had reviewed the investigation.
The incident report indicated it had been reviewed and completed by an RN on 10/17/23.
The incident was not reported to the Department.
3) During an interview on 12/07/23, Staff 18 (Med Tech) stated Resident 20 had been given Resident 13's Morphine, Oxycodone, and Lorazepam by another med tech and failed to notify anyone.
Resident 20's progress notes, dated 09/18/23, indicated s/he had accidentally been given another resident's medication and that his/her blood pressure was 98/55. Progress notes further indicated management had instructed staff to "get her up out of bed as soon as I could and was told to get her something caffeinated so I bought her a soda from the vending machine."
There was no documented evidence of an investigation conducted by the facility.
The incident was not reported to the Department.
4) Incident reports for Resident 28, dated 05/17/23, indicated s/he had suffered a fall with injury.
There was no indication the facility investigated the incident immediately and adequately to rule out abuse, nor was there an indication an Administrator had reviewed the investigation.
The incident was not reported to the Department.
5) Incident reports for Resident 37, dated 07/12/23, 07/13/23, 07/14/23, 08/15/23, and 09/27/23 indicated Resident 37 had suffered unwitnessed falls resulting in injury.
There was no indication the facility investigated the incident immediately and adequately to rule out abuse, nor was there an indication an Administrator had reviewed the investigation.
An incident report for Resident 37, dated 09/16/23, indicated s/he had suffered unwitnessed falls resulting in injury. There was no indication the facility investigated the incident immediately and adequately to rule out abuse. The incident report was completed by Staff 4 (Executive Director) on 09/19/23.
The incidents was not reported to the Department.
Findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Director of Operations), Staff 2 (Regional Director of Health Services), Staff 5 (Executive Director), and Staff 29 (CEO) on 12/11/23.
It was confirmed the facility failed to properly investigate and immediately notify the local Department office of multiple instances in which abuse or suspected abuse could not be ruled out.
Verbal plan of correction: In service training for staff beginning immediately. A new administrator has been hired. Setting up formal systems including a drop box for incident reports and daily stand up with leadership team to review incidents.
Based on observation, interview, and record review, conducted during a site visit on 12/04/23, 12/05/23, 12/07/23, 12/08/23 and 12/11/23, it was confirmed the facility failed to establish and maintain infection prevention and control protocols. Findings include, but are not limited to:
1. On 12/04/23 Resident 11 tested positive for COVID.
During an interview on 12/04/23 Staff 3 (LPN) stated the facility was trying to test all residents but was out of COVID tests.
During an interview on 11/04/23, Staff 6 (CG) stated s/he had changed Resident 11 but did not know s/he had COVID
On 12/05/23 LCU was notified a second resident had tested positive for COVID. Staff were unable to confirm which resident had tested positive.
Staff were observed on 12/04/23, 12/05/23, 12/07/23, 12/08/23 and 12/11/23 not wearing masks.
2. During an interview on 12/07/23 Staff 4 (Executive Director) stated the facility did not have an infection control specialist.
During an interview on 12/11/23 Staff 1 (Regional Director of Operations) stated the facility did not have an infection control specialist.
Staff were observed on 12/04/23, 12/05/23, 12/07/23, 12/08/23 and 12/11/23 not wearing masks.
3. During an interview on 12/04/23, Staff 7 (CG) stated the facility "frequently" runs out of briefs, gloves, masks, and trash bags, and that "someone will go to Fred Meyer if we need briefs".
During an interview on 12/04/23, Staff 9 (Activities) stated "we do run out of supplies" such as gloves, briefs, and wipes.
During an interview on 12/05/23, Staff 8 (MT) stated "it seems like we're always running out of wipes, gloves, [and] toilet paper."
During an interview on 12/05/23, Staff 14 (MT) stated the facility had run out of gloves and a CG "had to go buy [gloves] with [his/her] own money."
On 12/05/23 Staff 16 (CG) stated the following:
-All hand soaps in every hall were out;
-"We all run out of gloves and wipes;"
-There were "no custodial people at all" and s/he had been "wiping dried poop off of the walls;"
-The laundry was out of detergent, so they had been using a resident's detergent;
-That morning the hall s/he was working in had run out of large and extra large briefs, and had one package of wipes left.
On 12/05/23 LCU confirmed the facility was using a resident's detergent as the laundry detergent was out, that there was only package of wipes in the hall, and the hall was out of large and extra large briefs.
On 12/05/23 Staff 3 (LPN) stated the facility had been short on supplies, "mainly gloves".
On 12/07/23 Staff 15 (MT) stated the facility sometimes had "no supplies" such as gloves, wipes, and briefs.
During an interview on 12/08/23, Witness 8 stated the facility had been out of briefs and s/he had bought some and brought them in his/herself.
Confirmed. Verbal POC: Administration to review infection control protocols with staff 12/11/23 through 12/13/23. Infection control specialist will be new ED once they are trained. Facility has hired additional housekeeping staff through agency and walked every room for housekeeping. Facility is currently stocked with supplies and signs are in place.
Based on observation and interview, conducted during a site visit on 12/04/23, 12/05/23, 12/07/23, 12/08/23, and 12/11/23 it was determined the facility failed to fully implement an Acuity Based Staffing Tool (ABST) for 4 of 4 sampled residents (#s 2, 3, 15, and 18). Findings include, but are not limited to:
During an interview on 12/11/23, Staff 1 stated the ABST should be updated upon move-in, anytime a resident experiences a change in condition, and anytime a resident's service plan was updated.
A review of the facility's ABST indicated the following:
*The facility used the ODHS ABST;
*The facility's posted staffing plan did not match the ABST generated staffing plan as there were two care staff assigned to the 200 hall on 12/11/23 when the ABST indicated there should be three;
*The ABST was not reflective of resident's needs for Residents 3, 15, and 18 as indicated by their service plans; and
*The facility's ABST had not been updated for Resident 2 who was experiencing a change of condition.
Findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Director of Operations), Staff 2 (Regional Director of Health Services), Staff 5 (Executive Director), and Staff 29 (CEO) on 12/11/23.
It was determined the facility failed to fully implement an Acuity Based Staffing Tool.