Based on interview, observation, and record review, the facility failed to keep medical and other records confidential. Findings include, but not limited to:
A review of the facility's records indicated there are 34 residents that reside on the first floor. There was no first floor service plan binder to review and the service plans in the second floor service plan binder contains resident personal and confidential information.
In separate interviews on 06/29/2022, Staff 1, 2, 3, 5, 9, and 10 (S1-3, S5, S9-10) stated they have not seen the first floor service plan binder and did not know where it was. Staff stated that it's been about two weeks since it was last seen.
During an unannounced inspection on 06/29/2022, the Compliance Specialists (CSs) observed with S1 who searched four different offices with no avail.
On 06/29/2022, these findings were reviewed with and acknowledged by S1 and Staff 11.
Plan of Correction:
Effective immediately, the Administrator or designee will print out all first floor service plans, launch an investigation and within 14 days notify affected residents.
Based on interview, observation, and record review, it was confirmed the facility failed to ensure service plans were updated quarterly. Findings include, but not limited to:
In separate interviews on 06/29/2022, Staff #1, 2, 3, 4, and 5 (S1-S5) stated the resident's service plans are known to be outdated, the first floor service plans have not been seen for approximately 2 weeks.
A review of the resident and facility records including service plans indicated that following:
* Resident 3's (R3) service plan, dated 04/27/2022 was printed for CS and omits instances of falls in his/her history, and in a temporary service plan, dated 06/17/2021, interventions to prevent re-occurrances including the use of gait belt was not reflected in care plan.
Review of the second floor service plan binder indicated the following:
* Resident 4's (R4) service plan was dated 01/24/2021;
* Resident 5's (R5) service plan was dated 06/07/2021;
* Resident 6's (R6) service plan was dated 05/06/2021; and
* Resident 7's (R7) service plan was dated 01/26/2021;
During an unannounced inspection on 06/29/2022, the Compliance Specialist (CS) observed the facility did not have service plan binder for review for residents residing on the first floor.
On 06/29/2022, these findings were reviewed and acknowledged by Staff #1 and #11. S1 stated that he/she is the process of hiring a licensed practical nurse (LPN) to address service planning and evaluations.
Facility Plan of Correction:
Within 60 days, the Administrator or designee will hire an LPN to assist with service plan updates and effective immediately will conduct evaluations and update Service Plans.
Action Taken or Planned:
On 07/08/22, the Wellness Director located the original 1st floor Service Plan Binder in a box in a locked location.
An email was sent to the Compliance Specialist on 07/08/22 to inform the original binder was located.
Action to Prevent Reoccurrence:
The Service Plan Binder(s) are now located in an area accessible by both Med Techs and Caregivers on each floor.
The Wellness Director will monitor whereabouts of the binders.
Action Evaluation Frequency:
This will be observed outgoing and continuously.
Responsible Staff:
The Executive Director, Wellness Director, and RCC
Date the Facility Alleges Compliance:
July 08, 2022
Based on interview and record review, it was confirmed the facility failed to carry out medication and treatment orders as prescribed. Findings include, but not limited to:
In an interview on 06/29/2022, Staff #1 stated that some medications including [anti-convulsion] medications for diseases are time senstive and staff are expected to administer medications within a 30 minute window.
A review of Resident #1 and Resident 3's (R1-R3) medication administrator records, dated March 2022 and June 2022, indicated the following:
*R1 missed two doses of medications on 06/15/2022;
*R3 is ordered to receive [anti-convulsion] medication 5 times per day.
*R3's [anti-convulsion] medication history dated March 2022, indicated 22 different occurrances in which this medication was administered as much as 53 minutes after the prescribed order.
On 06/29/2022, these findings were reviewed with and acknowledged by S1 and Staff 11.
Plan of Correction:
Within 60 days, the Administrator or designee will provide in-servicing to medication technicians and conduct routine audits.
Actions Taken or Planned:
Community has partnered with Cynthia McDaniel from Elderwise as a consultant to assist with improving the overall medication administration program.
Community has signed up for "Med Tech Training Backfill Program - Nurse Crisis Team (NCT) Staffing Support" so the Executive Director, Wellness Director, and RCC can (re)-train staff on policies and procedures regarding Medication Administration.
Community is working on scheduling a system's conversation from QuickMar to PCC before the end of the year.
Clinical Team will meet daily to go over QuickMar dashboard to observe medications times and problem solve around any concerns or issues.
Action to Prevent Reoccurrence:
During the "Med Tech Training Backfill Program" the current employed Med Techs will be (re-)trained on policies and procedures regading Medication Administration.
Clinical team will meet daily to go over QuickMar dashboard to observe medications times and problem solve around any concerns or issues.
RN/LPN/RCC will audit medication administration time, consult with physician, and make any necessary changes to make system more efficient.
Action Evalution Frequency:
The Wellness Director and RCC will be auditing and monitoring the systems for accuracy and efficiency daily and continuously.
Responsible Staff:
The Executive Director, the Wellness Director, and RCC.
Date the facility Alleges Compliance: 11/01/2022
Based on interview, observation, and record review, it was confirmed the facility failed to have direct care staff sufficient in numbers to meet the scheduled and unscheduled needs of the resident. Findings include, but not limited to:
In separate interviews on 06/29/2022, Staff #1 - 5 (S1-S5), and Resident 1 (R1) stated the following:
*Staffing in the morning is okay, but we get complaints on evening shift about items not getting done.
*There are 2 residents that require 2 staff members for transferring and assistance.
*There is often only 1 medication technician (MT) on duty at night and only 1 care giver (CG) and 1 MT on duty in evening.
*There are no activities due to no coordinator; and
*The facility is not adequately staffed yet, but [supervisory or management] staff have covered shifts.
A review of the facility's posted staffing plan on 06/29/2022, indicated the facility is to have on day shift between 6 a.m. - 2:15 p.m. there are to be 2 MT and 2 CG; on evening shift between 2p.m. - 10:15 p.m. there are to be 2 MTs and 2 CGs; and on night shift between 10p.m. and 6:15 a.m. there is to be 1 Universal Worker.
A review of the facility's staff schedule, dated June 2022, indicated the facility consistently staffed the facility with only 1 Universal Worker.
A review of Resident #3's Service Plan indicated that he/she requires the assistance of two staff persons for all transfer and activities of daily living (ADLs).
During an unannounced inspection on 06/29/2022, the Compliance Specialist (CS) observed on swing shift the facility short staffed by 1 CG.
On 06/29/2022, these findings were reviewed with and acknowledged by S1 and S11.
Facility Plan of Correction:
Effective immediately, the facility will call-in it's Residential Care Coordinator (RCC) and/or Director of Wellness to ensure night shift is covered.
Actions Taken or Planned:
The Executive Director has hired another qualified awake Med Tech to meet the 24-hour scheduled and unscheudled care needs of the 60-70 residents in accordance with OAR 411-054-0070(1) on the NOC shift. Therefore, there are 2 Med Techs in the building during the night to assist with transferring assistance.
The Executive Director has hired a Life Enrichment Director on 07/07/2022.
Action to Prevent Reoccurrence:
The Executive Director continues to recruit for current open positions. During the recruitment time, the community is utilizing an outside agency to fill in any open shifts to meet staffing needs and requirements.
Action Evaluation Frequency:
This is area will be on going and continuously observed
Responsible Staff:
The Executive Director, Wellness Director, and RCC.
Date the facility alleges compliance: September 15, 2022.