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 04/04/2023. 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 that the facility failed to document the investigation of abuse. Findings include but not limited to:
During a joint interview, Staff #1-Staff #2 (S1-S2) stated:
*Resident #2 (R2) 's family called to notify that R2 indicated that Staff #6 had hit R2.
*S2 attempted to interview R2 at that time.
*They did not document the investigation.
The facility was unable to produce any documentation of an investigation for this incident.
These findings were reviewed with and acknowledged by S1 on 04/04/2023 who was in agreement.
Plan of Correction: CS to provided ODHS abuse reporting and investigation guide. Facility RN and Resident Care Coordinator (RCC)have now been trained on how to complete incident reports. Facility to ensure any reported/suspected abuse is reported within 24 hours and investigated.
Based on observation, interview and record review it was confirmed that the facility failed to complete resident service plans quarterly, failed to have service plans be reflective of needs, failed to provide clear directions and failed to have resident service plans readily available to staff. Findings include but not limited to:
During an unannounced site visit on 04/03/2023 CS observed service planning binders stored in the locked medication room.
Compliance Specialist (CS) reviewed Resident #1(R1) and Resident #4-Resident #6 (R4-R6) service plan which revealed two of four service plans had not been updated in the last quarter. R6's service plan stated that R6 is occassionally incontinent of bladder. Shower days are not listed.
During separate interviews, Staff #1 (S1) and Staff #3 (S3) stated:
*They have been working to update and complete service plans.
*S3 just received more training in March 2023 on how to update service plans.
*R6 has a catheter.
These findings were reviewed with and acknowledged by S1 on 04/04/2023 who was in agreement.
Plan of Correction: Facility to ensure that all service plans are current within 30 days. Resident Care Coordination (RCC) and RN to complete service plans within 30 days and submit to Executive Director (ED) for review. S1 to relocate service plan binders to an area accessible by caregivers by end of day 04/04/2023.
Based on record review and interview, it was confirmed that the facility failed ensure adequate professional oversight of the medication and treatment administration system. Findings include but not limited to:
During an unannounced site visit on 04/04/2023 Compliance Specialist (CS) reviewed Resident #2 (R2)'s progress notes and Medication Administration for April 2022 and incident report dated 4/7/2022 which revealed that R2 received the wrong medication on 4/1/2022. A review of medication error report dated 3/19/23 Resident #3's progress notes for March 2023 and a Facility self-report form dated 3/20/2023 revealed that R3 received a double dose of a medication on 3/19/2023. A review of narcotic count verification sheets for March 2023 and December 2022 revealed 21 instances in which narcotic counts were not signed off on as verified. A review of an incident report and investigation worksheet for an incident that occurred 12/24/2022-12/25/2022 revealed that a Medication Technician (MT) lost a pill off the medication cart and the pill was found by another MT on 12/31/2022. A review of the facility's Narcotic Count policy dated 06/08/2017 revealed that narcotics are to be counted at the beginning and end of every shift.
During interview, Staff #3 (S3) stated that the MT on 3/19/2023 had pre-popped a narcotic for R3 which lead to the medication error and that they provided education on administering narcotics after the incident. S3 stated that they thought the medication from the 12/24/2022 incident had been lost but was later found by another MT in the cart.
These findings were reviewed with and acknowledged by Staff #1 (S1) on 04/04/2023 who was in agreement.
Plan of Correction: Resident Care coordinator to audit narcotic logs five days/week.
Facility to provide Medication Technician Training in partnership with Consonus pharmacy by end of month and continuing monthly. Facility to offer additional training called " How to avoid medication errors " through Relias.
Based on record review and interview, it was confirmed that the facility failed to implement a system for tracking controlled substances. Findings include but not limited to:
During an unannounced site visit on 04/04/2023, Compliance Specialist (CS) reviewed narcotic correct count verification sheets for March 2023 and December 2022 which revealed 21 instances in which narcotic counts were not signed off on as verified. A review of an incident report and investigation worksheet for an incident that occurred 12/24/2022-12/25/2022 revealed that a Medication Technician (MT) lost a pill off the medication cart and the pill was found by another MT on 12/31/2022.
A review of the facility's Narcotic Count policy dated 06/08/2017 revealed that narcotics are to be counted at the beginning and end of every shift.
During interview Staff #3 (S3) stated that they thought the medication had been lost but was later found by another MT in the cart.
These findings were reviewed with and acknowledged by Staff #1 (S1) on 04/04/2023 who was in agreement.
Plan of Correction: Resident Care coordinator to audit narcotic logs five days/week.
Based on record review and interview, it was confirmed that the facility failed to carry out medication and treatment orders as prescribed. Findings include but not limited to:
During an unannounced site visit on 04/04/2023 Compliance Specialist (CS) reviewed Resident #2 (R2)'s progress notes and Medication Administration for April 2022 and an incident report dated 4/7/2022 which revealed that R2 received the wrong medication on 4/1/2022. A review of medication error report dated 3/19/23 Resident #3 (R3)'s progress notes for March 2023 and a Facility self-report form dated 3/20/2023 revealed that R3 received a double dose of a medication on 3/19/2023.
During interview, Staff #3 (S3) stated that the MT on 3/19/2023 had pre-popped a narcotic for R3 which lead to the medication error and that they provided education on administering narcotics after the incident.
These findings were reviewed with Staff #1 (S1) on 04/04/2023 who was in agreement.
Plan of Correction: Facility to provide Medication Technician Training in partnership with Consonus pharmacy by end of month and continuing monthly. Facility to offer additional training called " How to avoid medication errors " through Relias.
Based on interview and record review, it was confirmed that the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include but not limited to:
During an unannounced site visit on 04/04/2023, Compliance Specialist (CS) reviewed the facility's staff schedule for April 2023 which revealed that on 04/02/2023 two Medication Technicians (MTs) and two Caregivers (CGs) were scheduled on day shift. A review of the facility's posted staffing plan revealed the need for two MTs and three CGs on day shift. A review of Resident #5 (R5)'s Individual Account Report (call light log) for 04/02/2023-04/04/2023 revealed seven instances when R5's call light was on for more than 30 minutes, including one incident that lasted 1:43:49 and one that lasted 3:11:57.
During interview, Staff #1 (S1) stated that staff are expected to respond to call lights within 15 minutes.
During separate interviews, Resident #1 (R1), R5 and Resident #7 (R7) stated:
*They have been left in the bathroom for up to three hours.
*Their average wait time for a response to their call light is an hour and a half.
*There is not enough staff.
*The call light doesn't always get a response.
*They were short handed yesterday (04/03/2023).
These findings were reviewed with (S1) by phone on 04/05/2023.
Plan of Correction: S1 declined to provide a plan of correction and stated they would reach out to their corporate office for input.
Based on record review and interview, it was confirmed that the facility failed to fully implement an Acuity-Based Staffing Tool (ABST). Findings include but not limited to:
During an unannounced site visit on 04/04/2023, Compliance Specialist (CS) reviewed the facility's ABST for 04/03/2023 which revealed:
*The ABST included 15 Activities of Daily Living (ADL) categories.
*18 residents ABST profiles have not been updated in the last quarter.
*They needed 95.6 hours of care.
A review of the facility's staff schedule for April 2023 revealed 11 employees scheduled on 04/03/2022 including two Medications Technicians (MTs) and two Caregivers (CGs) scheduled on day shift. A review of the facility's posted staffing plan revealed the need for two MTs and three CGs on day shift. A review of Resident #5 (R5)'s Individual Account Report (call light log) for 04/02/2023-04/04/2023 revealed seven instances when R5's call light was on for more than 30 minutes, including one incident that lasted 1:43:49 and one that lasted 3:11:57.
During interview Staff #1 (S1) stated:
*The facility has 8 hour shifts so 95.6 / 8 = 11.95 staff so they need 12 staff per day.
*They do not take into account a half hour lunch for each employee.
*Staff are expected to respond to call lights within 15 minutes.
During separate interviews, Resident #1 (R1), R5 and Resident #7 (R7) stated:
*They have been left in the bathroom for up to three hours.
*Their average wait time for a response to their call light is an hour and half.
*There is not enough staff.
*The call light doesn't always get a response.
*They were short handed yesterday (04/03/2023).
These findings were reviewed with and acknowledged by S1 on 04/04/2023 who was in agreement.
Plan of Correction: Facility to ensure that all care plans, which feed their ABST, are current within 30 days. Facility is not tracking all 22 ADLs and will discuss with their regional/corporate staff. Facility to request permission from corporate to use agency staff when not staffed to level required by ABST.