The findings of the on-site investigation, conducted on 09/14/23 , are documented in this report. The investigation 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.
Abbreviations possibly used in this document:
ADL:activities of daily living
CBG:capillary blood glucose or blood sugar
CG:caregiver
CS: Compliance Specialist
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
LPN:Licensed Practical Nurse
MT: Medication Tech
MAR:Medication Administration Record
MCC:Memory Care Community
OT:Occupational Therapist
PT: Physical Therapist
PRN:as needed
RCC:Resident Care Coordinator
RN:Registered Nurse
Based on interview and record review, conducted during a site visit on 09/14/23, it was confirmed the facility failed to ensure the completeness, accuracy, and preservation of resident records for 5 of 7 sampled residents (#s 1, 2, 3, 4, and 5) whose records were reviewed. Findings include, but are not limited to:
Compliance Specialist reviewed Resident 1, 2, 3, 4, and 5s' August 2023 Medication Administration Records (MARs), progress notes, doctor's orders, and the facility's alert charting log and incident reports. Documents indicated Residents1, 2, 3, 4, and 5s' all had missed medication on 08/22/23 as indicated by their progress note, incident report, or alert charting log; however, documentation on the MAR reported that the medications were given.
During separate interviews, Staff 1 (ED) stated s/he did their own investigation of the incidents on 08/22/23. S/he stated, "they were given and documented, but they were not popped on the right day". Staff 1 stated that s/he had not documented his/her investigation or findings. S/he also stated that they had been doing a lot of retraining on medication administration since s/he started in August 2023. Staff 4 (CG) stated s/he had two med errors at the same time. S/he stated they "signed it out on the MAR and forgot to pop it " so they are "no longer passing meds".
The findings were reviewed with and acknowledged by Staff 1 on 09/14/23.
It was confirmed the facility failed to ensure the completeness, accuracy, and preservation of resident records.
Verbal plan of correction: Staff received in-service training last week on Wednesday (Sept 6th) and the RN, ED, MT lead, and RCC will be having a "boot camp" for the med techs. Training will be provided on documentation, ordering/re-ordering medications, and the 3-check system. A lead MT was hired, there have been increased MT meetings, and the RCC will start auditing the MAR and pulling missed med reviews next week to ensure medications are being administered as ordered.
Based on interview and record review, conducted during a site visit on 09/14/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 5 of 7 sampled residents (#s 1, 2, 3, 4, and 5) whose MARs were reviewed. Findings include, but are not limited to:
Compliance Specialist reviewed Residents 1, 2, 3, 4, and 5s' August 2023 Medication Administration Record (MAR), progress notes, doctor's orders, and the facility's alert charting log and incident reports. The following discrepancies were found:
a. Resident 1's records indicated:
·Alert charting log reported "missed meds" for 08/22/23;
·MAR showed medications as given on 08/22/23; and
·Progress note dated 08/24/23 at 2:09 am reported Resident on alert charting for "missed meds" on 08/22/23.
b. Resident 2's records indicated:
·Alert charting log reported "missed meds" for 08/22/23;
·Medication incident report dated 8/22/23 reported that resident did not receive 8 am medications;
·MAR showed medications as given on 08/22/23; and
·Progress note dated 08/26/23 at 1:54 am reported resident on alert charting for "missed medication 8/22".
c. Resident 3's records indicated:
·Alert charting log reported "missed med" 08/22/23;
·MAR showed medications as given on 08/22/23; and
·Progress note dated 8/24/23 at 9:32 am reported resident on alert charting for "missed medication".
d. Resident 4's records indicated:
·Alert charting log reported "missed med" 08/22/23;
·MAR showed medications as given on 08/22/23; and
·Progress note dated 8/26/23 at 2:11 am reported resident on alert charting for "missed medication".
e. Resident 5's records indicated:
·Medication incident report, dated 08/22/23, reported resident did not receive their 8 am medications;
·There were no entries in the progress notes regarding alert charting for missed med
·MAR showed medications as given on 08/22/23;
* MAR indicated Resident 5 did not recieve their 12 pm dose of Cephalexin 500 mg capsule due to waiting on med from pharmacy; and
·MAR indicated on 08/12/23, 08/13/23, and 08/14/23 Resident 5 did not recieve their Trazadone HCL 50 mg tablet due to awaiting med from pharmacy or Doctor needs to be called for refill.
During separate interviews, Staff 1 (ED) stated s/he did their own investigation of the incidents on 08/22/23. S/he stated, "they were given and documented, but they were not popped on the right day". Staff 1 stated s/he had not document his/her investigation or findings. S/he also stated that they had been doing a lot of re-training on medication administration since s/he started in August 2023. Staff 4 (CG) stated s/he had two med errors at the same time. S/he stated they "signed it out on the MAR and forgot to pop it" so s/he was "no longer passing meds" .
The findings were reviewed with and acknowledged by Staff 1 on 09/14/23.
It was confirmed the facility failed to carry out medication and treatment orders as prescribed.
Verbal plan of correction: Staff received in-service training last week on Wednesday (Sept 6th) and the RN, ED, MT lead, and RCC will be having a " boot camp " for the med techs. Training will be provided on ordering/re-ordering medications and the 3-check system. A lead MT was hired, there have been increased MT meetings, and the RCC will start auditing the MAR and pulling missed med reviews next week to ensure medications are being administered as ordered.