Print Inspection: BHU3

The findings of the re-licensure survey conducted 11/2/21 through 11/3/21 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 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

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 re-visit to the re-licensure survey of 11/03/21, conducted 1/05/22, 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 notify the physician when a resident refused to consent to orders for 3 of 3 sampled residents (#s 3, 4 and 5) who had documented medication refusals. Findings include, but are not limited to:

1. Resident 3's clinical records and October 1, 2021 through November 1, 2021 MARs were reviewed and revealed the resident had multiple medication refusals.

There was no documented evidence the facility notified the physician when the resident refused consent to their orders.

On 11/3/21, the failure to notify the physician of the documented medication refusals was reviewed with Staff 1 (Director). She acknowledged the findings.

2. Resident 5's clinical records and October 1, 2021 through November 1, 2021 MARs were reviewed and revealed the resident had multiple medications and treatment refusals. Clinical documentation revealed the physician requested to be notified weekly of refusals.

There was no documented evidence the facility notified the physician when the resident refused consent to their orders.

On 11/3/21, the failure to notify the physician of the documented medication and treatments refusals was reviewed with Staff 1 (Director). She acknowledged the findings.

3. Resident 4 was admitted to the facility in 3/2021 and with diagnosis including chronic failure.

The resident's 8/1/21 through 11/1/21 progress notes, 10/1/21 through 11/1/21 MARs and physician's orders were reviewed and revealed the following:

The resident had a physician's order for continuous oxygen at 2 liters per minute.

On 11/1/21 and 11/2/21, observations were made of an oxygen tank and concentrator in the resident room, were was not in use.

In an 11/1/21 interview with the resident, s/he communicated not using the oxygen tank or concentrator.

In an 11/2/21 interview with Staff 1 (Director), she stated the resident did not want to use oxygen and had not in some time.

The facility lacked documented evidence the prescriber was notified of the resident's refusal to consent to the order for continuous oxygen.

The requirement to notify the prescriber of a resident's refusal to submit to a physician's order was discussed with Staff 1 and Staff 2 (RN Consultant) on 11/3/21. They acknowledged the findings.

1.  On 11/10/21, the medication passers were retrained on the policy, procedure and requirements for notifying the prescriber when a resident, or the person legally authorized to make health care decisions for the resident, refuses medications or treatments.

2.  Practitioners will have the opportunity to record their preferences for notifications on the move in orders for new residents.  Current residents' practitioners have been contacted to determine the frequency of notification they prefer.  

3.  The electronic medication and treatment administration records will be reviewed with the practitioner notifications weekly to ensure notifications are completed.  

4.  It will be the responsibility of the licensed nurse and director to ensure the weekly audit is completed and appropriate updates for notifications recorded.  

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 7, 11 and 12) had demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to:

Review of the facility's training records on 11/2/21 indicated the following:

Staff 7, 11 and 12 (CGs), hired on 7/16/21, 8/17/21 and 9/13/21 respectively, lacked documented evidence of demonstration of competency in assigned duties within 30 days of hire date.

The need to ensure staff had documented evidence of competency demonstration in assigned duties, within 30 days of their hire date, was discussed with Staff 1 (Director) on 11/3/21. She acknowledged the findings.

1.  On 11/10/21, staff members involved with orientation and training of new direct care staff members were retrained on the requirements and documentation of knowledge and performance within the first 30 days of hire.  Instructions for pre-service orientation and 30-day orientation/training checklists were reviewed.

2. New direct care staff will be assigned to specific trainers and the trainers will be responsible for completion of the orientation, training, competency determination and corresponding checklists.

3.  The new staff member's file will be placed in pending until all documentation is completed.  Prior to 30 days after hire, the file will be reviewed and any missing documentation obtained.  All current direct care staff members' files will be audited and competency review documentation completed, if not in the file. The system will be evaulated monthly.  

4.  The director will review for completion prior to 30 days after hire.  The licensed nurse will be responsible for the training documentation for delegated tasks, medication management and administration.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to:

Observations during the survey revealed the exit door near Resident Room number 114 and exit doors to courtyard lacked alarms or other acceptable systems to alert staff when residents exited the building.

The need to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building was discussed with Staff 1 (Director) and Staff 2 (RN Consultant) on 11/3/21. They acknowledged the findings.

1. Electronic door alarms integratable with the call system have been obtained for the 2 courtyard doors.  A technician has been scheduled for installation.      The emergency only exit door near apartment 114 is locked at all times and has a magnetic door lock controlled by the fire alarm system.  The door can also be opened with a master key entrusted to specific staff members, including the medication passer on duty, maintenance manager and director.

2.  The call system will be upgraded with added electronic alarms for the courtyard doors. The call system/electronic alarms will be evaluated monthly.

3.  The courtyard doors are used daily by residents and staff members.  The alerts will be monitored through the call system which will be evaluated monthly  

4.  The director and maintenance will monitor the call system to ensure the alerts are captured.