Print Inspection: 0L5F

The findings of the re-licensure survey conducted 09/11/23 through 09/14/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first revisit to the re-licensure survey of 09/14/23, conducted on 11/30/23, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on interview and record review, it was determined the facility failed to investigate incidents or injuries of unknown cause to rule-out abuse, document all required areas of an investigation and report to the local SPD office, if abuse or neglect could not be ruled out, for 1 of 2 sampled residents (#1) with incidents or injuries of unknown cause. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 11/2021 with diagnoses including pain in right hip joint.

Observations of the resident, interviews with staff, review of the resident's service plan, 06/11/23 through 09/11/23 temporary service plans and progress notes and incident investigations were reviewed, and the following was identified:

* 06/28/23 injury of unknown cause, right hip;

* 07/09/23 injury of unknown cause, "severe cut"; and

* 07/24/23 injury of unknown cause, "open skin on bottom".

There was no documented evidence the occurrences had been investigated at the time of occurrence and the investigations included all required components, or the occurrences reported to the local APS office, if abuse and/or neglect could not be ruled out.

At the request of the survey team, all incidents above were reported to APS.

The need to ensure injuries of unknown cause were immediately investigated, contained all required areas of documentation, including if abuse and neglect could be ruled out and if not, the injuries were reported to the local APS office, was discussed with Staff 1 (Administrator) and Staff 10 (RN) on 09/14/23. They acknowledged the findings.

In addition, to being reviewed with newly hired employees, the policy for Abuse and Neglect reporting will be reviewed with staff as a CEU topic at least quarterly to help ensure their ongoing understanding and proper implementation of the policy for responding to injuries of unknown origin.

This will include direction that such injuries, when detected, are to be reported to admin for prompt investigation.  Further describing that admin will report to APS unless an immediate facility investiation reasonably concludes and documents that the physical injury is not the result of abuse.

Administration will ensure that a documented investigation is completed for each report.  If abuse and neglect is ruled out then facility policies and procedures will be followed to ensure that we respond to the occurrence with a evaluation of potential causes or contributors including medication, mobility assistance, inclusion of PT/OT/Nursing involvment or conditions specific to the resident to adjust plan of care if needed.

Administrator will over see this area of correction.  

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed and progress was documented weekly until resolution for 1 of 3 sampled residents (#1). Findings include, but are not limited to:

Resident 1 was admitted to the facility in 11/2021 with diagnoses including right hip pain.

Observations of the resident, interviews with staff, and review of the resident's service plan, 06/11/23 through 09/11/23 temporary service plans and progress notes, physician communications, and incident investigations were completed.

The following short-term changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or progress noted at least weekly through resolution:

* Multiple skin changes;

* Multiple medication changes; and

* New behaviors.

The need to ensure actions or interventions for short-term changes of condition were documented, communicated to staff on each shift, and the changes of condition were monitored through resolution was discussed with Staff 1 (Administrator) and Staff 10 (RN) on 09/14/23. They acknowledged the findings.

The areas that were identified to be deficient for follow up for short term changes of conditions, lacking documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff were:

A) Multiple skin changes

B) Multiple medication changes

C) New behaviours

Plan of correction:

To provide corrective action to prevent this deficiency from re occurring staff will continue to receive training as requireed as a 30 day training requirement but will also receive ongoing training at least quarterly to help ensure staff's knowledge in identifying, documenting and  monitoring through resolution of a short term change of condition. The annual CEU's of 12 hours will be listed to staff to require general topics, 6 hours of dementia specific topics, infection control and change of condition.

Administrator and RN will include this topic at least quarterly in our meetings to discuss our curriculum and system to update as needed.   Administrator and Nurse will provide oversight and implementation of this system.

Based on observation, interview, and record review, it was determined the facility failed to ensure devices with restraining qualities were assessed by an RN, PT, or OT prior to use and evaluated quarterly, and instruction was provided to staff on the correct use and precautions related to the devices, for 1 of 1 sampled resident (#1) who had devices with potentially restraining qualities. Findings include, but are not limited to:

Observation of Resident 1's room 09/11/23 through 09/14/23, revealed there were bilateral half-length side rails in the raised position on the bed and a tilt-in-space wheelchair. Resident 1 required a hoyer lift for transfers and had cognitive impairment which rendered him/her unable to adjust the position of the wheelchair independently, and therefore required an assessment.

Review of the resident's clinical record revealed the following:

There was no documented evidence the following required elements were completed for the side rails:

* Quarterly evaluation; and

* Instruction provided to staff on the correct use and precautions related to the device.

There was no documented evidence the following required elements were completed for the tilt-in-space wheelchair:

* Assessment by an RN, PT or OT;

* Documentation of less restrictive alternatives evaluated prior to use of the device;

* Instruction provided to staff on the correct use and precautions related to the device; and

* Documentation of a tilt-in-space wheelchair in the resident's service plan.

The need to ensure devices with restraining qualities were assessed by an RN, PT, or OT prior to use and evaluated quarterly, and instruction was provided to caregivers on precautions and correct use of the devices, was discussed with Staff 1 (Administrator) and Staff 10 (RN) on 09/14/23. They acknowledged the findings.

Administrator will work with RN consultant to help create a list of items that meet the criteria for supportive devices with restraining properties as the OAR's do not identify detailed equipment.

A form or check list will be created for use with each assessment completed by PT, OT or Nursing so that the required elements of the assessment are consistently included.  This form will be placed into the service plan binder so that care staff have access to it, so that it can be reviewed and updated on a quarterly basis as well as needed for changes in residents cognition or care. quarterly updates will be scheduled to align with quarterly service plan updates and will be tracked by administrator and nurse who is managing oversight of our community.  A list of supportive devices identified in need of this assessment will be kept available for admin and nursing review during routine visits to allow them to calendar and manage timelines.

Administrator and facility Nurse will provide monitoring for this system.

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 newly hired direct care staff (# 5) demonstrated competency of skills in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed on 09/13/23 and 09/14/23 and identified the following:

Staff 5 (CG) hired on 07/11/23, lacked documentation of demonstrated competency in the following areas:

* Providing assistance with ADL's;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

* Conditions that require assessment, treatment, observation and reporting; and

* First Aid and abdominal thrust.

The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 (Administrator) on 09/14/23. She acknowledged the findings.

Administrator presently uses a check list for the purpose of tracking and completing required  a) pre service and b) 30 day required training. The example in this survey was an administrative oversight of not following through on completion of the 30 day training required.

The corrective plan,  so that this violation does not happen again, is as follows:

The check list for the 30 day requirements will now include a box where a meeting date can be logged that Admin and the new hire will schedule to allow a sit down opportunity to review and document completion of these requirements.  This meeting will be scheduled shortly after the DOH but no later than 25 days from date of hire.

Administrator will provide monitoring and implementation of this corrective action.