The findings of the on-site investigation, conducted 07/19/23 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 on 07/19/23, it was confirmed the facility failed to implement written policies to ensure resident monitoring and reporting system is implemented 24-hours a day for 1 of 1 sampled resident (#1). Findings include, but are not limited to:
A review of an incident report dated 04/03/23 revealed Resident 1 fell in his/her room around 8:58 pm. The incident report stated "confusion internal between AED (Assisant Executive Director) and RSM (Resident Services Manager) notification to family occurred 04/04/23 at around noon. Community [facility] nurses had discussion with hospice and family to address miscommunication. In the future staff member responding to fall will complete notifications." Resident record indicated Resident 1 was on service with Providence Elderplace, not hospice. An incident report for the occurence revealed the healthcare provider was notified at 12:10 pm on 04/04/23.
During an interview on 07/18/23, Witness 1 (Elderplace RN) reported s/he was at the facility to see a different patient on 04/04/23 when a staff member asked him/her if they were there to see Resident 1. Witness 1 stated the staff member explained at this time that Resident 1 had sustained a "really bad fall". Witness 1 stated they then saw Resident 1, who had a steristrip on his/her eyebrow, and blood on his/her face and ear. Witness 1 stated the provider had not previously been notified of the resident's fall.
During an interview on 07/19/23, Staff 4 (RN) stated it is facility policy to noticy a provider if a resident has a fall with injury.
The findings were reviewed with and acknowledged by Staff 1(Assistant Administrator), Staff 2 (Assistant Director of Operations for Mosaic), Staff 3 (Administrator), Staff 4, Staff 5 (LPN) , Staff 9 (RSS) and Staff 10 (RSS) on 07/19/23.
The facility failed to implement written policies to ensure resident monitoring and reporting system is implemented 24-hours a day.
Verbal plan of correction: The facility started a group chat with nursing staff and administrator for staff to report incidences to receive 24 hour support and guidance. Administration and nursing staff guide staff through notifications, placing residents on alert and notifying providers and any additional supports needed. Facility reviewed the policy for notifying providers and family at MT meeting on 07/26/23.
Based on interview and record review, conducted during a site visit on 07/19/23, it was confirmed the facility failed to implement safe medication systems. Findings include, but are not limited to:
1. A review of Resident 1's signed physician orders dated 05/11/23, May 2023 MAR, progress notes dated 04/02/23 through 05/21/23, and interviews with Staff 6 (MT) on 07/19/23 and Witness 8 (Elderplace RN) on 07/18/23, confirmed Resident 1 did not receive fentanyl patches as prescribed.
2. A review of Resident 2's signed physician orders dated 04/21/23, April 2023 MAR, progress notes dated 04/03/23 through 04/27/23, and an interview with Staff 4 (RN) indicated Resident 2's orders were not transcribed to the MAR and Resident 2 did not receive lasix or morphine as prescribed.
During an interview on 07/19/23, Staff 4 stated the facility was having difficulty with their fax machines in April of 2023. During that time the facility did not have a centralized med room and faxes were going to five separate fax numbers, one for each facility neighborhood. S/he stated the facility had difficulty ensuring the faxes went to the correct neighborhood. Staff 4 further stated that all new orders were to go through a triple check process for accuracy.
A review of Resident 1's 05/11/23 physician orders and Resident 2's 04/21/23 physician orders revealed they did not go through the triple check process.
The findings were reviewed with and acknowledged by Staff 1(Assistant Administrator), Staff 2 (Assistant Director of Operations for Mosaic), Staff 3 (Administrator), Staff 4, Staff 5 (LPN) , Staff 9 (RSS) and Staff 10 (RSS) on 07/19/23.
The facility failed to implement safe medication systems.
Verbal plan of correction: The facility has begun conducting bi-weekly MT meetings to go over trainings and system issues. Facility nurses and administration have completed weekly MAR, narcotic and med cart audits. The facility has started staffing a " mid-shift MT " position, which was developed out of these issues. This position was in addition to the MTs working on the floor and was responsible for inputting new orders and communicating with providers. They centralized their med room so that orders are not going to five separate fax machines. Nurses have rounded daily in the med room. They have re-implemented their triple check system with orders being verified as follows: 1. MT 2. Resident Services Specialist 3. LPN or RN.
Based on interview and record review, conducted during a site visit on 07/19/23, it was confirmed the facility failed to carry out medication orders as prescribed for 2 of 2 sampled residents (#s 1 and 2). Findings include, but are not limited to:
1. A review of Resident 1's signed physician orders dated 05/11/23, May 2023 MAR, and progress notes dated 04/02/23 through 05/21/23 indicated the following:
* On 5/11/23 the facility received a fax to increase Resident 1's fentanyl patch dose from 12 mcg to 25 mcg every three days.
* On 5/12/23 Staff documented in the MAR a 12 mcg patch had been applied.
* On 05/13/23 Staff 6 (MT) documented in Resident 1's progress notes s/he had removed Resident 1's 12 mcg patch and applied a 25 mcg patch. This was not documented in the MAR.
* On 05/15/23, staff document on the residents MAR they applied a 25 mcg patch.
During an interview on 07/19/23, Staff 6 stated s/he had removed the 12 mcg fentanyl patch on 05/12/23 and applied a 25 mcg patch, which s/he documeted in Resident 1's progress notes at the direction of the facility RN.
During an interview on 07/19/23 Staff 4 (RN) stated s/he was not aware staff had applied a 25 mcg patch on Resident 1 without removing the previously applied patch.
During an interview on 07/18/23, Witness 8 (Elderplace RN) stated a facility MT had reported to him/her staff had applied a fentanyl patch to Resident 1 on 05/15/23 and failed to remove the old patch, which could have caused an overdose. Witness 8 stated s/he reproted the incident to APS.
2. A review of Resident 2's signed physician orders, April 2023 MAR and progress notes dated 04/03/23 through 04/27/23 indicated the following:
* On 04/21/23 the facility received a faxed physician order to increase Resident 2's Lasix from one 20 mg tablet once daily, to two 20 mg tablets once daily, and to to increase the administration of morphine from four times a day to every four hours.
* A review of Resident 2's April 2023 MAR indicated the new orders had not been transcribed to the MAR.
*Resident 2 died on 04/27/23.
During an interview on 07/19/23, Staff 4 confirmed the new orders for lasix and morphine had not been transcribed to the MAR and did not occur as ordered by the physician.
The findings were reviewed with and acknowledged by Staff 1(Assistant Administrator), Staff 2 (Assistant Director of Operations for Mosaic), Staff 3 (Administrator), Staff 4, Staff 5 (LPN) , Staff 9 (RSS) and Staff 10 (RSS) on 07/19/23.
The facility failed to carry out medication orders as prescribed.
Verbal plan of correction: The facility has begun conducting bi-weekly MT meetings to go over trainings and system issues. Facility nurses and administration have completed weekly MAR, narcotic and med cart audits. The facility has started staffing a " mid-shift MT " position, which was developed out of these issues. This position was in addition to the MTs working on the floor and was responsible for inputting new orders and communicating with providers. They centralized their med room so that orders are not going to five separate fax machines. Nurses have rounded daily in the med room. They have re-implemented their triple check system with orders being verified as follows: 1. MT 2. Resident Services Specialist 3. LPN or RN.