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 11/01/2022. 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 has been confirmed that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. Findings include:
During an unannounced site visit on 11/1/2022, Compliance Specialist (CS) interviewed the following staff separately; Staff #1 (S1), Staff #3 (S3), Staff #4 (S4) and Staff #5 (S5) Resident #1(R1) and Resident #3(R3). R3 stated that call light response times can take up to one hour if care staff are assisting with a two-person transfer. R3 stated they call the front desk by telephone to request assistance if their call light request is not getting a response. R1 stated that they were in bed until 10:00 am due to not having a caregiver to assist with getting them out of bed and dressed. S1 stated residents use the call light to request a staff member to pick up and move a computer charger and this slows down response times, for example.
S1 stated they assist with showers and other care tasks in the absence of enough caregivers to complete care tasks.
In a review the call light response times, (iAlert/Pendant calls) dated 08/20/2022 through 08/22/2022, it was recorded that the longest response time was fifty-five minutes and fifty-three seconds.
These findings were reviewed with S1 and S2 on 11/01/2022. No further information was provided.
Facility Plan of Correction: Facility to operate a staffing plan of two Med Techs (MT) and two Caregivers (CG) during day and swing shift and one MT & one CG for night shift. The facility is actively interviewing, hiring, and training new staff. The facility provides incentives to staff including shift competitions with prizes and a $50.00 gift card to the caregiver with the fastest call light response time.
Based on interview, observation and record review, it has been confirmed that the facility failed to fully implement an acuity-based staffing tool (ABST). Findings include but not limited to:
During an unannounced site visit on 11/01/2022, Compliance Specialist (CS) interviewed Staff #1 (S1) and Staff # 2 (S2) regarding the implementation of the ABST. S1 and S2 stated the facility is currently in the process of adopting the Oregon Department of Human Services (ODHS) ASBT.
Upon review of Resident #3's (R3) ABST assessment on 11/01/2022, it was revealed the last update occurred on April 13th 2022. A change of condition discovered for Resident #1 (R1) and the caregiving time needed for that task was not reflective on the ABST.
On 11/01/2022, CS observed on the computer screen of S2 that the total caregiving hours worked for the full week of 10/23/2023 to 10/29/2022 was 265.46. S2 divided this number by seven to represent the seven days of the week, then divided by three to represent the three daily shifts. This equates to twelve carestaff per shift. This number of staff does not match the posted staffing plan.
On 11/01/2022, CS reviewed the above information with S1 and S2 who were in agreement.
Facility Plan of Correction: The facility will update all ABST assessments quarterly, service plan reviews, and changes of condition or a significant change. As the facility transitions to using the ODHS ABST, caregiving hours will be taken into account to inform the staffing schedule.