The findings of the on-site investigation, conducted 11/13/23 through 11/14/23 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.
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, conducted during a site visit 11/13/23 through 11/14/23, it was confirmed the facility failed to implement the resident's right to receive services in a manner that protects privacy and dignity for 1 of 1 sampled resident (#6). Findings include, but are not limited to:
A photo provided by Adult Protective Services was reviewed. Staff 8 (CG) can be seen in the facility with Resident 6 in the background. Resident 6's face was visible in the photo and a caption read, "When its St Patrick's Day but you're stuck at work instead of partying." The photo was posted to social media.
During a phone interview on 11/10/23, Witness 1 (former facility staff) stated s/he saw the picture on social media.
During interview on 11/14/23, Staff 6 (Administrator) stated she was aware of the photo being posted to social media and had immediately spoken with the Staff 8 about it.
The findings were reviewed with and acknowledged by Staff 6 on 11/14/23.
It was confirmed the facility failed to implement the resident's right to receive services in a manner that protects privacy and dignity.
Verbal plan of correction: Administrator discussed with staff in question and will review HIPAA at shift change meetings within one week.
Based on interview and record review, conducted during a site visit from 11/13/23 through 11/13/23, it was confirmed the facility failed to implement written policies and procedures on medical emergency response for all shifts for 1 of 1 sampled resident (#5). Findings include, but are not limited to:
A review of Resident 5's progress notes dated 01/01/23 through 01/14/23 revealed:
*On 01/08/23 Resident 5 had an unwitnessed fall with injury. Progress notes did not indicate that facility nurse or Resident 5's family were notified, or note any attempts to notify.
*On 01/09/23 Resident 5 had another unwitnessed fall with injury. Facility RN, ED and family were notified.
*Resident 5 passed away on 01/14/23.
A review of the facility's minor/major injuries policy and procedure indicated:
"All minor emergencies/injuries shall be reported to the family and/or responsible person as soon as possible... notification of family and/or responsible person will be documented in the progress notes in the Resident's file."
During an interview on 11/14/23, Staff 6 (Administrator) stated Resident 5's family and the facility nurse should have been notified of Resident 5's 01/08/23 fall immediately, but were not.
The findings were reviewed with and acknowledged by Staff 6 on 11/14/23.
The facility failed to implement written policies and procedures on medical emergency response for all shifts.
Verbal plan of correction: MT meeting to review incident reports and minor/major injuries policy and procedure was conducted at 2 pm on 11/14/23.
Based on interview and record review, conducted during a site visit 11/13/23 through 11/14/23, it was confirmed the facility failed to fully implement an Acuity-Based Staffing Tool (ABST). Findings include, but are not limited to:
The facility had an active ABST Condition: RCDCD23- 00369, with the following staffing standards imposed:
Day: 3 CGs, 2 MTs
Swing: 2 CGs, 1 MT
Noc: 2 CGs, 1 MT
A review of time cards for 10/29/23 - 11/4/23 revealed day shift on 10/31/23, 11/2/23 and 11/04/23 were staffed short of the imposed staffing requirements.
In an interview on 11/14/23, Staff 6 (Administrator) stated the facility had several call-outs that week and agreed they were short of the imposed staffing standards.
The findings were reviewed with Staff 6 on 11/14/23.
The facility failed to fully implement an ABST.