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 01/11/2023. 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 as confirmed the facility failed to treat the resident with dignity and respect. Findings include:
During separate interviews on 01/11/2023, Staff #1 (S1) and Resident #1 (R1) both stated that during assistance with toileting a Caregiver (CG) made derogatory comments toward the resident. R1 stated the comments made them uncomfortable and embarrassed. S1 stated once aware of the treatment they had an in-service with all staff members reminding them of resident ' s rights.
A review of the facility ' s policy and procedure for residents ' rights dated 01/07/2008 and the employee in-service attendance summary dated 12/22/2022. The attendance summary shows the facility went over sharing information with family and residents, job descriptions, proper phone etiquette, break policy, sleeping on shift, pictures/ videos of staff or residents, resident rights, and abuse and neglect. The attendance shows signatures of all staff acknowledging they went through and understand the training. The policy for residents ' rights shows the first item listed is residents are to be treated with dignity and respect.
On 01/11/2023, these findings were reviewed and acknowledged by S1.
Plan of Correction: S1 stated that the whole facility went through an in-service training on 12/22/2022 and S1 has followed up with R1 to ensure the comments have stopped.
Based on interview and record review it was confirmed the facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents. Findings include:
During separate interviews on 01/11/2023, Resident #1 (R1) stated they do not feel there is enough staff and on occasions has had to wait awhile for staff to answer their call lights. Staff #3-4 (S3 and S4) stated that there are only 2 Caregivers (CG) on day shift. The CG ' s have to deliver meals and while one is doing that the other is answering call lights. They stated that during this time they are unable to assist residents who are 2 person transfers until after the other CG is finished delivering meals. S3 and S4 stated that the facility has three 2-person transfer residents. S3 also stated concerns about providing assistance when one CG goes on break, there is only one CG to provide assistance. S3 and S4 stated that needs are being met but are delayed due to lack of staffing.
A review of the call light response time log from 12/22/2022-12/23/2022 and 01/07/2023- 01/08/2023, the posted staffing plan and the staff schedule for December 2022 and January 2023. The call light logs revealed there are 31 calls that exceeded the facility ' s 15-minute response time, with the longest time being 43 minutes wait
On 01/11/2023, these findings were reviewed and acknowledged by Staff #1 (S1).
Plan of Correction: S1 stated that they will add another caregiver to the day shift to ensure call lights response times aren ' t long and no residents needs are delayed.