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 10/27/2022.  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 orient direct care staff to the resident. Findings include:

Review of facility Incident Report and Investigation Worksheet dated 09/15/2022, Investigation, and witness statement reveal that Staff # 3 was unaware of Resident # 1 having a POLST with DNR in place and direct care staff started CPR against resident wishes.

Interview with Staff # 1 and Staff # 2 on 10/27/2022 with both stating that Staff # 3 did not know that Resident # 1 had a POLST with DNR.  

Facility Correction Plan: Facility provided in-service training on 10/25/2022 on POLST and CPR to staff.