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 01/19/2023. 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 respond to the resident's change of condition. Findings include but not limited to:
During an unannounced site visit on 1/19/2023, Staff #4 explained what staff is to do when a resident falls or has a change of condition:
*Check vitals and pain levels.
*See if resident is injured.
*Start an incident report.
*Contact managers including nurse and executive director.
*Contact family and resident's primary care physician.
*Put Interim Service Plans (ISP) in place with interventions and place in 24 hour binder.
*Review ISPs at shift change and document in the shift change meeting.
*Staff are to review the 24 hour binder daily at the beginning of their shift.
A review of the the 24 hour binder revealed that Resident #5 (R5) had ISP's dated 1/18/2023 and 1/19/2023 that had not yet been reviewed in a shift change meeting. A review of the facility's neighborhood shift change meetings revealed one had not occurred since 1/11/2023.
During interview Staff #5 stated they had not yet reviewed the ISP for R5 as it was their 'Monday.'
These findings were reviewed with Staff #3 (S3) by phone on 1/20/2023.
Plan of Correction: Executive Director (ED) to add shift huddle review to daily standup review to be audited with Resident Services Manager and ED with daily follow up to verify that ISP has been input into shift huddle. ED has submitted a formal request to add signature pages to ISP.
Based on interview and record review it was confirmed that the facility failed to administer the resident's medication as ordered by their physician. Findings include but not limited to:
During an unannounced site visit on 1/19/2023, Compliance Specialist reviewed an Adult Protective Services (APS) self-report document stating that Resident #1 (R1) was given a medication at a time it was not scheduled. A review of R1's Medication Administration Report (MAR) for November 2022 revealed an instance where a medication was not charted as given. A review of Resident #3's (R3) progress notes for August 2022 revealed that the resident had not been getting an ordered medication since April 2022.
During interview Staff #3 (S3) stated that R3's medication was left off the MAR when they changed systems in April 2022 and that both incidences were self-reported to APS. S3 stated that they get an email daily with any mischarted medications, which required follow up from appropriate staff within the same business day.
Plan of Correction: Facility completed verbal medication error training with staff member. Medication Technician (MT) medication administration training to continue monthly and daily Quality Assurance (QA) to review any missed medications.
Based on observation and interview it was confirmed that the facility failed to ensure a resident may not be locked out of or inside of their room at any time. Findings include but not limited to:
During an unannounced site visit on 1/19/2023 Compliance Specialist (CS) observed the family of a resident approach the medication station and state that their mother was locked out of her room and request that Staff #4 (S4) let them in.
During interview, Staff #4 stated that sometimes staff lock doors so that other residents can't get in, but that residents are good about asking to be let into their rooms.
These findings were reviewed with Staff #3 (S3) on 1/19/2023 who was in agreement.
Plan of Correction: Executive Director (ED) to complete staff training at shift huddle beginning 1/19/2023. ED will submit formal request to update policy by end of day 1/20/2023.