The findings of the on-site investigation, conducted 08/15/23 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.
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, conducted during a site visit on 08/15/23, it was confirmed the facility failed to provide a safe and homelike environment for 1 of 1 sampled resident (# 9). Findings include, but are not limited to:
A review of the facility's call light log on 11/26/22 for Resident 9 revealed that s/he engaged his/her pendant at 10:37 pm and it was not cleared until 10:59 pm (22 minutes).
During an interview on 08/15/23, Resident 9 stated S/he remembered the man coming into his/her room and was very scared at the time. S/he further stated his/her biggest concern was that s/he could not reach anyone to help get the man out for over 20 minutes. S/he used his/her pendant and no one responded. S/he then called a family member who was able to call the front desk and get someone to respond and get the man out of her room.
During an interview on 08/15/23, Staff 1 (Administrator) said their goal was to respond to call lights within 10 minutes.
The findings were reviewed with and acknowledged by Staff 1 on 08/15/23.
Based on interview and record review, conducted during a site visit on 08/15/23, it was confirmed the facility failed to provide a safe and homelike environment
Verbal plan of correction: Staff 1 believed this incident was mostly related to their call light system. They have a call light escalation of alerts now: alert goes to iphone, after three minutes it sends a text, then it calls the med room and texts again. If unanswered, calls/emails are sent to the RCC and Administrator. Admin receives a report daily with any calls over 10 minutes and sends to RCC to follow up with staff.
Based on interview and record review, conducted during a site visit on 08/15/23, it was confirmed the facility failed to follow a service plan that was reflective of the resident's needs for 1 of 1 sampled resident (# 10 ). Findings include, but are not limited to:
A review of Resident 10's service plan dated 03/07/23 and point of care charting for February 2023 revealed Resident 10 was to receive assistance with showering twice weekly. There was no documentation on the point of care charting that indicated s/he received a shower from 02/08/23 through 02/28/23.
During interview on 08/15/23, Staff 1 (Administrator) confirmed that Resident 1 was not showered for three weeks.
The findings were reviewed with and acknowledged by Staff 1 on 08/15/23.
The facility failed to follow Resident 2's service plan regarding providing the resident with showers twice weekly.
Verbal plan of correction: Facility implemented shower/skin sheets which required two signatures for refusals and are then reviewed in standup by clinical team for care planning updates and interventions. POC charting weekly audits are conducted every Thursday and missed documentation was reviewed. The facility had a POC charting competition that resulted in a Taco party for staff with best charting practices.
Based on interview and record review, conducted during a site visit on 08/15/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but are not limited to:
In an interview on 08/15/23, Staff 1 (Administrator) stated, "On 03/11/23, a medication error occurred, and the facility filed a self-reported medication error form to APS. I am not sure why the staff signed out administering imodium when Pepto- Bismol was given. The Pepto-Bismol was removed from the medication cart immediately."
On 08/15/23, CS attempted to speak to Resident 8 who was unable to recall or discuss the medication error that occurred on 03/11/23, however did state, "I have not taken Pepto-Bismol in months."
A review of the facility self-report, dated 03/11/23 stated the following:
·Two tablets of Pepto-Bismol were given.
·Two tablets of Imodium were not given.
·Two tablets of Imodium were signed out.
·The wrong medication was administered at 1:00 am on 03/11/23.
A review of Resident 8's MARs dated 03/01/23-03/31/23, showed two orders for Imodium, one to give one tablet by mouth every hour as needed and one to give two tablets by mouth every hour. On 03/11/23 the MARs showed the order for one tablet was signed off as given to Resident 8.
It was confirmed the facility failed to carry out medication and treatment orders as prescribed.
On 08/15/23, the findings were reviewed with and acknowledged by Staff 1.
Verbal plan of correction: Provided coaching and education to that employee. Reviewed training for NOC shift MTs who are to be trained on swing shift. Medication was removed from the med cart.
Based on interview and record review, conducted during a site visit on 08/15/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5). Findings include, but are not limited to:
In an interview on 08/15/23, Staff 1 (Administrator) stated, "On 11/22/22 there was a massive Covid outbreak and residents who were Covid positive were moved to a separate wing and provided their own medication cart. There was some miss communication between staff members and five residents missed their medications."
Staff documented on the facility self-report, dated 11/23/22, "due to rapid increased Covid positive residents our staffing assignments were being shifted with a goal of providing dedicated staff to our Covid positive residents. As we shifted assignments the person responsible for passing the 2:00 pm medications to the back hall Covid positive residents were not clearly defined causing confusion for the oncoming staff. Subsequently, the 2:00 pm meds were not given." Medications not given were as listed,
·Resident 3 missed their 2:00 pm Tylenol.
·Resident 4 missed their 2:00 pm Tylenol.
·Resident 5 missed their 2:00 pm Tylenol.
·Resident 6 missed their 2:00 pm Tylenol and Gabapentin.
·Resident 7 missed their 4:00 pm Tylenol.
It was confirmed the facility failed to carry out medication and treatment orders as prescribed.
On 08/15/23, the findings were reviewed with and acknowledged by Staff 1.
Verbal plan of correction: Facility is working to reduce agency staffing. Have built a stable staff. Immediate intervention conducted with health services manager who provided written directions for covering agency staff.