Print Inspection: 0W1N

The findings of the relicensure survey, conducted 02/03/22 through 02/04/22, 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 for 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

MCC:Memory 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 re-visit to the re-licensure survey of 02/04/22, conducted 04/27/22 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on interview and record review, it was determined the facility failed to monitor short-term changes consistent with evaluated needs and service plan until resolution for 1 of 2 sampled residents (#2). Findings include, but are not limited to:

Resident 2 was admitted in 12/2021 with diagnoses which included anxiety and a urinary catheter.

Resident 2's progress notes, home health notes, nursing assessments, and TSP's (temporary service plans) reviewed from 12/10/21 - 02/04/22, indicated the following:

* The facility initiated short-term change monitoring when the resident moved in. Staff were instructed to monitor and document the following on "all shifts": Mental status, how resident was adjusting, safety issues, signs of anxiety, odd behavior and wandering. Resident 2's clinical record lacked monitoring of the resident's status on all shifts until resolved.

* Facility progress notes, dated 01/02/22, indicated the resident had complaints of stinging and itching when urinating. A TSP was initiated the same day and staff were instructed to monitor and document the following on "all shifts": Pain, ongoing symptoms, appetite, vital signs and other complaints. The resident's clinical record lacked documented monitoring of the resident's condition on all shifts until resolved.

Failure to monitor short term changes of condition based on evaluated needs and service plan, and with weekly progress noted until resolution was reviewed with Staff 2 (Consultant RN), Staff 3 (Assistant Administrator) and Staff 4 (Personal Care Director) on 02/04/22. They acknowledged the findings.

Facility Administrator, Facility Contract RN, and Personal Care Director reviewed processes and procedures with all PCA's. Facility Contract RN and Personal Care Director will review progress notes and change of conditions at least weekly and document follow up and findings until conditions are resolved.

Reporting changes of conditions: Monthly ongoing review & training during inservices with PCA's & Personal Care Director, Facility RN on reporting changes and processes for our 24/7 reporting procedures. We are revising our alert charting system. Ongoing education regarding changes of conditions will be provided to the staff on monthly basis.

PCD and RN will do a weekly audit check on progress notes and resident records to ensure that PCA's are documenating follow ups properly and notifying PCD/RN and/or Administrator of any changes. PCD, RN and/or Administrator will be responsible for being the individuals who can identify when a resident's change of condition has been resolved and can be removed from monitoring for that condition.

Administrator will do at minimum a monthly review of a random resident record, orders, MARs and progress notes.

Based on observation, interview and record review, it was determined the facility failed to ensure adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to:

Administrative oversight of the medication administration system was found to be ineffective based on deficiencies identified in the following areas:

C303: Systems: Medication and Treatment Orders; and

C310: Systems: Medication Administration: and

C330: Systems: Psychotropic Medications.

The requirement to ensure adequate professional oversight of the medication administration system was discussed with Staff 2 (Consultant RN), Staff 3 (Assistant Administrator) and Staff 4 (Personal Care Director) on 02/04/22. They acknowledged the findings.

Administrator, PCD and RN reviewed areas of concern.  

All medication orders will be reviewed by both PCD and/or RN before being initiated.

RN and/or PCD (or designee) will call and fax for clarification with ordering provider as needed the same day the new order arrives. PCD or designee will follow up each day until resolved.

PCA's have been instructed to notify PCD and/or RN when there is a new medication order.

Ongoing weekly audit reviews of a sample resident of the MAR's against orders will be initiated by facility RN. Monthly reviews of MAR' and Orders will be conducted by facility RN, PCD and/or Designee.

Quarterly reviews of medication room and medications will be conducted by Pharmacist and/or RN.

Administrator, PCD and/or RN will be conducting ongoing monthly education and inservices to our PCA's and PCD regarding change of condition and monitoring, resident specific needs or concerns and/or doctors orders.

PCD and/or RN will check HH records 1-2 times a week at minimum for review of any outstanding concerns that may have been noted. In addition, we also did a review with reception staff to notify outside care providers upon entering the facility that they must communicate with Personal Care Office during visit.

Based on observation, interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 2 sampled residents (#2) whose orders were reviewed. Findings include, but are not limited to:

Resident 2 was admitted in 12/2021 with diagnoses including a urinary catheter.

Primary Care Physician (PCP) orders, HH (home health) documentation, Clinic After Visit Summaries and MARs, reviewed from 01/01/22 through 02/04/22, revealed the following:

a. Facility Progress Notes, dated 01/02/22, indicated the resident complained of stinging and itching when urinating.

On 01/04/22, a HH nurse documented that the resident had "severe yeast in peri [perineal] area - will call MD."

On 01/07/22 the resident was seen by a physician in an Urgent Care Clinic. The "After Visit Summary Medication List" provided during the visit noted the resident was to be on Nystatin cream "apply topically 2 times a day" for "yeast dermatitis".  There was no evidence in the record that the facility inquired about the medication from the clinic or contacted the PCP to clarify.

In an interview on 02/04/22 at 1:00 pm, Staff 2 (Consultant RN) and Staff 4 (Personal Care Director) reviewed the record. They stated the facility should have compared the After Visit Summary Medication List with current orders and contacted the PCP to clarify/obtain a written order so the medication could be initiated.

b. On 01/12/22 the facility sent a fax to the PCP indicating that "family just brought in a prescription for Nystatin cream and Fluconazole [antifungal medication used to treat fungal infections]  ... can we please have orders for the medication."

On 01/18/22, the PCP replied that the medications were a "treatment for condition ...take meds as prescribed."

During an observation of the container of Nystatin Cream on 02/04/22, interview with Staff 4 (Personal Care Director) on 02/04/22 at 1:20 pm, and review of the MARs from 01/18/22 - 02/04/22, the following was revealed:

* The container of Nystatin cream indicated it was to be applied "topically 2 times daily";

* On 01/18/22, Staff 4 wrote the order onto the MAR instructing staff to apply the cream twice a day PRN (as needed) versus routinely twice a day;  

* From 01/18/22 - 02/04/22, the resident only received the cream six times;

* On 01/25/22, the facility received another order for "Nystatin Cream: apply 2 times daily"; and

* The 01/25/22 Nystatin cream order was never transcribed onto the MARs, therefore staff did not apply it as ordered.

In a further interview with Staff 4 on 02/04/22 at 1:30 pm, she reviewed the MAR and acknowledged PCP orders were not followed.

c. On 01/25/22, Staff 2 (Consultant RN) documented in facility progress notes that the resident "continued with rash in peri area". She sent a fax to the PCP the same day requesting "OK to apply Nystatin ...cream to rash 2 times a day until resolved?" The PCP approved the request on 01/27/22.

Review of the MARs, from 01/27/22 - 02/04/22, revealed the Nystatin order was never transcribed onto the MARs. As a result, staff did not apply the cream as ordered.

d. On 02/02/22, a HH nurse documented that the resident "C/O [complained of] itching and discomfort to vaginal region - upon assessment, rash to groin/inner thighs ...advised pt. [patient] to seek urgent care for possible yeast infection."

The resident was seen in Urgent Care on 02/02/22, was diagnosed with Vulvovaginal Candidiasis, and was ordered treatments including Triamcinolone Cream twice daily.

Review of the 02/2022 MAR revealed the order for Triamcinolone cream had not been added, nor was there documentation that staff were applying it as ordered.

On 02/04/22 at 1:40 pm, the medication cart was observed with Staff 4 and Staff 5 (MT). They stated the Triamcinolone cream was obtained on 02/02/22. Staff 4 and 5 were unable to verify if staff were applying it as ordered.

Failure to ensure orders were followed was discussed with Staff 2 (Consultant RN), Staff 3 (Assistant Administrator) and Staff 4 (Personal Care Director) on 02/04/22. They acknowledged the findings.

Administrator, PCD and RN reviewed areas of concern.  

All medication orders will be reviewed by both PCD and/or RN and/or before being initiated.

RN and/or PCD (or designee) will call and fax for clarification with ordering provider as needed the same day the new order arrives. PCD or designee will follow up each day until resolved.

PCA's have been instructed to notify PCD and/or RN when there is a new medication order.

Ongoing weekly audit reviews of a sample resident of the MAR's against orders will be initiated by facility RN and/or PCD.

Monthly reviews of MAR' and Orders will be conducted by facility RN, PCD and/or Designee.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 2 of 2 sampled residents (#s 1 and 2) whose medications were reviewed. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 12/2021.

Resident 2's MARs, reviewed from 01/01/22 - 02/04/22, revealed the following inaccuracies:

* Reasons for use was not indicated for all medications;

* S/he had orders dated 01/25/22 and 01/27/22 for Nystatin cream twice a day for yeast infection. The orders were either incorrectly written on the MAR or not transcribed onto the MAR;

* The resident had an order dated 02/02/22 for Triamcinolone cream twice daily for Vulvovaginal Candidiasis that was not transcribed onto the MAR;

* Staff failed to consistently document effectiveness of PRN medications administered;

* Several PRN medications were initialed as given. However, there was no supporting documentation on the back of the MAR that indicated time administered and reason; and

* Staff initials for several medications were circled. However, there was no documentation that explained why they circled their initials.

On 02/04/22, the need to ensure MARs were accurate was discussed Staff 2 (Consultant RN), Staff 3 (Assistant Administrator) and Staff 4 (Personal Care Director) on 02/04/22. They acknowledged the findings.

2.  Resident 1 was admitted to the facility in 2021.

Residents 1's MARs were reviewed from 01/01/22 through 02/03/22 and the following was noted:

* Reasons for use was not indicated for all medications.

In an interview on 02/04/22, the need to ensure MARs were accurate was discussed Staff 2 (Consultant RN), Staff 3 (Assistant Administrator) and Staff 4 (Personal Care Director) on 02/04/22. They acknowledged the findings.

Administrator conducted a meeting and reviewed findings with all staff including PCD and RN.

RN, Administrator and/or PCD will provide ongoing monthly training to PCA's regarding follow ups and effectiveness to PRN medication. PCD will monitor MARs on a weekly basis to ensure follow up is consistent and she will follow up with PCA's who are not following standards to provide further education.

Orders for new medications will be kept in a binder next to MAR's for reference for staff. Orders are also in Resident Chart for reference. Education has been provided and will continue to be provided regarding proper inscribing in MARs.

PCD and/or RN will do a weekly random audit check on MARs for accuracy. Any new orders will be reviewed by either the PCD and/or RN. PCD and RN will also meet with facility Pharmacist in March 2022 to review findings regarding "reasons for use" being dropped off the MARs.

They will have an additional audit system in place for new monthly MAR's. PCD will have designee, and/or RN and self review MAR's on monthly basis as new MAR sheets come in from Pharmacist as well.

Based on interview and record review, it was determined the facility failed to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 1 of 1 sampled resident (#2) who was prescribed PRN medications for behaviors. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 12/2021 with diagnoses including anxiety.

Resident 2 had a physician's order for Lorazepam 0.5 mg every eight hours as needed for anxiety.

Review of MARs and progress notes, from 01/01/22 - 02/03/22, revealed staff administered PRN Lorazepam on 37 occasions. There was no documented evidence staff had attempted non-drug interventions with ineffective results prior to administering the psychotropic medication.

In an interview on 02/04/22 at 9:00 am, Staff 4 (Personal Care Director) reviewed the record and acknowledged staff were not documenting non-drug interventions attempted prior to administering the Lorazepam.

The need to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications was reviewed with Staff 2 (Consultant RN), Staff 3 (Assistant Administrator) and Staff 4 during the exit interview. They acknowledged the findings.

Administrator conducted a full review of findings with PCA's, PCD and RN. Adminstrator discussed that residents may not "self-direct" psychotropic medications without a doctors order. Adminstrator will monitor this during at minimum monthly checks of MAR's.

Resident specific parameters and interventions are being placed directly in MAR's. Staff have been provided education regarding this.

PCD and/or RN will continue to monitor PRN medications and follow ups on a weekly basis during random MAR's review.

In addition, PCD will be attending Administrator course through OHCA in March 2022.