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 9/16/2022. 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 the facility failed to carry out medication and treatment orders as prescribed. Findings include:
In an interview on 9/16/2022, Staff #1 (S1) reported the following:
*A medication audit by the facility RN showed Resident #1 (R1) went without prescribed medications for 4 days.
*The medication was entered into R1's Medication Administration Record (MAR) as not administered because it had not been received from the pharmacy, when the medication had been entered incorrectly under a different resident's name.
*Record review of the facility's incident report and self report to Adult Protection Services dated 9/7/2022 supported S1's statement.
Record review on 9/16/2022 of Resident #1-2 (R1-2)s MARs revealed the following:
*R1 missed scheduled mediations for 4 days because they were not in the facility.
*R2's MAR reflected the addition of R1's medication in error, however R2 never received the medication.
On 9/16/2022, findings were reviewed and acknowledged by S1.
Plan of Correction:
Facility LPN did an internal investigation into the mixup with medications, several Med Techs were involved. All received in-service training on receiving and updated medications in MARs.