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 09/07/2022. 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 that the facility failed to carry out medication orders as prescribed. Findings include the following:
During an unannounced site visit on 09/07/2022 Compliance Specialist (CS) reviewed August and September 2022 Medication Administration Records (MARs) for Residents #1- #3 (R1-R3) which revealed instances on 3 of 3 residents MARs where medications are not marked as given and no reason listed for medication not given. 3 of 3 residents had medications not given due to medication not onsite. R1 has a placement specific medication that has consistently been placed on an alternative site than as prescribed.
According to Witness #1 (W1) a resident did not receive their morning insulin.
The above findings were shared with Staff #1 and Staff #2 (S1 & S2) who were in agreement.
Facility Plan of Correction:
The facility is moving to cycle fill rather than on demand to establish a better process for maintain medication stock. The variance and exceptions reports are now being reviewed everyday and any variances are being addressed immediately.
Based on interview, record review and observation it was confirmed that the facility failed to provide sufficient care staff to meet the scheduled and unscheduled needs of the residents. Findings include the following:
During an unannounced site visit on 09/07/2022 Compliance Specialist (CS) reviewed staff schedules for July, August and September 2022. The Department imposed licensing condition RCFCD22-00638, the facility Acuity Based Staffing Tool (ABST) and facility payroll for 07/12, 08/28 and 09/04/2022. The imposed licensing condition requires for Day and Swing shifts 9 caregivers and 2 med techs and for NOC shift 6 caregivers and 1 med tech. Facility staff schedules are not scheduling to required staffing levels. A review of facility payroll confirmed that has not been posting to required staffing levels.
In separate interviews with Staff #1 and Staff #2 (S1 & S2) the following was stated:
·The facility is running mostly 12-hour shifts, with a couple staff that work 8-hour shifts
·The facility is utilizing agency staff
·Even with agency staff the facility is still struggling to meet the requested updated staffing plan made to the Department of 6 Caregivers, 2 med techs and 1 float for Day and Swing and 4 caregivers and 1 med tech for NOC
During separate unannounced site visits on 09/06/2022 and 09/07/2022 Compliance Specialist observed less staff onsite than what is required by the facilities condition.