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 12/01/2022. 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 have a system in place to track controlled substances. Findings include:
CS reviewed Narcotic logs dated March-June 2022 for Resident #1, Internal incident report that was reported on 05/19/22, and policy and procedure for counting and disposal of controlled substances. Resident #1 had a narcotic documented as "not here" or "not found" from 05/10/22-05/19/22 which was not reported to the nurse right away per their policy and procedures. There was also no documentation of a police report being filed or reporting to APS.
In separate interviews on 12/01/22, Staff #1-3 stated that the narcotics count is done at the beginning and end of each shift. If the count is off, the nurse would be notified immediately.
The above information was shared with Staff #1 on 12/08/22 via phone call, who acknowledged the findings.
Plan of Correction:
The facility has had ongoing training regarding narcotics count and documentation in the book. Reminders that the nurse will be immediately notified if the count is off. Also went over reporting to the police and APS.
Based on interview and record review, it was confirmed that the facility failed to administer medications as prescribed. Findings include:
In an interview with Staff #1 on 12/01/22, Staff #1 stated that they have not seen or heard of any staff withholding medications from residents. They stated that they are reviewing the missed medications and progress notes daily.
CS reviewed Resident #1-4s medication administration records (MARs) and progress notes for June-August 2022. Resident #2 did not receive multiple medications as prescribed in August 2022 due to not having the medication available or awaiting delivery from pharmacy.
The above information was shared with Staff #1 on 12/08/22, via phone conversation, who acknowledged the findings.
Facility plans of correction:
Ongoing re-training to staff regarding medication re-ordering process. Contacting the pharmacy as needed. Facility may move to cycle fill in the future.