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 02/07/2023. 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 administer medications and prescribed. Findings include:
In review of Resident # 1's medication administration records (MARs) and progress notes for February and December 2022. Resident #1 did not receive a medication for multiple days due to the medication "not in house, waiting on new script".
The above information was acknowledged by Staff #1-2 on 02/07/23 and 02/14/23 via phone interview and email follow up.
In a phone interview on 02/07/23, Staff #1 stated that the facility has had a couple of issues with the pharmacy, and they have filed a formal complaint regarding their concerns. Providers were signing electronically, and they are not able to fax the pharmacy with digital signature, so this was causing a delay.
Plan of Correction: Facility has had group meetings with Hospice and the nursing team, talked to pharmacy to talk to providers, they recently had Survey at the building and are working with a consultant. They have also had some changes to their re-ordering process which seems to be working better.