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 09/08/2022. 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 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 August 2022 and Medication Incident Report for 08/26/22. Resident #1 received 6 doses of a medication that was put on hold. The facility failed to give medication as ordered in the MAR.
The above information was acknowledged by Staff #1-2 on 09/08/22.
In interviews on 09/08/22, Staff #1-2 stated that Resident #1 had a medication on hold, however, when cycle fill was put in on 08/20/22, a new card was placed in the resident 's basket. The morning med tech gave the medication because they did not check the medication against the MAR.
.
Plan of Correction:
Policy and procedures for medication administration reviewed with staff, system re-evaluated and corrections made. Staff member was written up and pulled off the cart to part time med passer.