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 12/05/2022. 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 record review and interview, it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include:
Compliance Specialist (CS) reviewed the Uniform Disclosure Statement (UDS) that reflects Shift Hours 6am-2pm Direct Care Staff 3 Medication Aid 1, 2pm-10pm Direct Care Staff 3 Medication Aid 1 and 10pm-6am Direct Care Staff 1 Medication Aid 1. CS reviewed the staff schedule for the month of December 2022. On 12/05/22 S1 stated current census was 31. CS reviewed ABST for 12/05/22 which shows the following: ABST reflects that not all residents are currently entered into tool. ABST reflects AM/day shift includes 30 residents (AM total care hours 24.23 and require a total of 4 caregivers/med-techs), PM/evening shift 29 (PM total care hours 21.8 and require a total of 3 caregivers/med-techs) and Graveyard shift 30 (Graveyard total care hours 8.92 and require a total of 2 caregivers/med-techs) out of current census 31 that require assistance with all activities of daily living (ADL) scheduled and unscheduled care needs. Current Resident Roster includes 32 residents in the facility. ABST does not represent or included all 22 ADL's for scheduled and unscheduled daily care needs for each of the 30 residents entered into tool. Review of residents #1-3 service plans (SP) reflects that not all residents' care needs are reflected in ABST acuity, therefore staffing hours are not calculated to reflect current resident care needs. R3's SP shows resident is on a complex medication regime for daily medication management; also requires follow up interventions after receiving medication for side effects daily. R3's SP reflects resident is bladder incontinent and requires extensive care daily. The above care mentioned is not reflected in ABST and is listed as PRN for daily required scheduled care needs.
In separate interviews with Staff #1 (S1), they stated they had been working hard to get all resident entered into system. They stated at quarterly review, staff is entering all ADL's for residents in ABST. S1 stated they cannot just remove ADLs from the service plans or the Acuity Based Staffing Tool (ABST) unless there is an evaluation done. The nurse or the administrator can only make changes by completing an evaluation in the Blue Step program. The evaluation or change in service would then carry over to the service plan and then be updated in the ABST.
On 12/05/22, these findings were reviewed with and acknowledged by S1.