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 02/07/2023. 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 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 02/07/2023, Compliance Specialist reviewed
Resident #1- #3 Medications Administration Records (MAR) for November 2022- January 2023 which revealed instances for each resident when medications were not given due to "Waiting for delivery from pharmacy."
During interview Staff #1-Staff #2 (S1-S2) stated they were not aware those medications were not given.
Plan of Correction: Resident Care Coordinator (RCC) to audit MARs/TARs and medication carts weekly for next two months. Nurse will review RCC findings.
Based on interview and record review, it was confirmed that the facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents. Findings include but not limited to:
During unannounced site visit on 02/07/2023, Compliance Specialist (CS) reviewed progress notes and Medication Administration Records (MARs) for Residents #1-3 (R1-R3) which revealed instances when showers were not provided due to "short staffed" or were rescheduled with no explanation. A review of the facility's Uniform Disclosure Statement dated 06/22/2022 revealed the facility needs two caregivers (CGs) and two medication technicians (MTs) on evening shift. A review of the facility's staff schedules for November 2022-February 2023 revealed that the facility is regularly scheduling two CGs and one MTs.
During interview, Staff #1-2 (S1-S2) stated:
*The facility is not using an Acuity-Based Staffing Tool.
*They were not sure why the showers were not given.
*The facility staffs based on an eight resident to one caregiver ratio.
These findings were reviewed with S1-S2 on 02/07/2022.
Plan of Correction: Facility Administrator to contact Operations and Policy Analyst on 02/07/2023 to gain access to facility' s ABST. Facility will have all resident data entered within three weeks. Resident Care Coordinator (RCC) to audit shower/skin sheets weekly for the next two months. RCC and Administrator to in-service MTs on documenting shower changes and reschedules.
Based on interview and record review, it was confirmed that the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include but not limited to:
CS requested documentation on how the facility determined the number of staffing plan and an undated document titled Resident High Touch List was provided. The document does not contain any resident names and is missing room 102 and 110.
During interview, Staff #1 (S1) stated:
*The facility is not using an Acuity-Based Staffing Tool.
*The facility is staffed based on an eight resident to one caregiver ratio.
*They are not sure when the provided acuity document was last updated.
These findings were reviewed with S1-S2 on 02/07/2022.
Plan of Correction: Facility Administrator to contact Operations and Policy Analyst on 02/07/2023 to gain access to facility's ABST. Facility will have all resident data entered within three weeks. Resident Care Coordinator (RCC) to audit shower/skin sheets weekly for the next two months. RCC and Administrator to in-service MTs on documenting shower changes and reschedules.
Based on observation, interview and record review, it was confirmed that the facility failed to document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised. Findings include but not limited to:
During an unannounced site visit on 02/07/2023 observed Staff #3 (S3) passing medications unsupervised to residents.
A review of S3's training documents revealed that no training document related to passing medications were available. Training documents related to other job duties were not signed as verified.
During interview, Staff #1-2 stated that the Resident Care Coordinator (RCC) or Administrator should verify all competencies.
Plan of Correction: Admin and RCC to audit all training documentation and ensure completion. Med Tech training and verifications to be completed within one week and another to be completed in three months.