Print Inspection: DCX3

Based on record review and interview it was confirmed that the facility failed to ensure a resident monitoring and reporting system is implemented 24-hours a day. Findings include but not limited to:

During an unannounced site visit on 03/09/2022, Compliance Specialist (CS) reviewed Resident #2 (R2)'s  progress notes, faxes to outside providers and temporary service plans for November 2022 which revealed that on 11/21/2022 resident had a change of condition. The facility nurse and family were not notified and a fax was sent to the Primary Care Physician (PCP).

During separate interviews, Staff #2- Staff #3 (S2-S3) stated:

*The Medication Technician (MT) should have notified the facility nurse and family of the change of condition.

*A call should have been made to notify the PCP for this instance instead of a fax.

*RN did not assess R2 after the change of condition was identified.

These findings were reviewed with and acknowledged by Staff #1 (S1) on 03/09/2023 who was in agreement.

Plan of Correction: RN to provide training to MTs on change of conditions and responding to emergencies within two weeks, reviewing all steps to be taken when a change of condition is notified.

Based on record review and interview it was confirmed that the facility failed to assist the resident by coordinating appointments with outside providers; and provide relevant information to the off-site provider. Findings include but not limited to:

During an unannounced site visit on 03/09/2022, Compliance Specialist (CS) reviewed Resident #2 (R2)'s  progress notes, faxes to outside providers and temporary service plans for November 2022 which revealed that on 11/21/2022 resident had a change of condition described as "dropy face, less talkative, freezing during transitions." The facility nurse and family were not notified and a fax was sent to the Primary Care Physician (PCP). On 11/22/2022 the resident was sent out via 911 to the hospital per PCP "due to increased confusion, possible UTI and difficulty getting her words out right." Administrator, RN and family were not notified. A review of R2's service plan revealed that R2 requires an escort for safety during transport and that family or friends will need to escort.

During separate interviews, Staff #2- Staff #3 (S2-S3) stated:

*The Medication Technician (MT) should have notified the facility nurse and family of the change of condition.

*The MT should print a facesheet, Medication Administration Record (MAR), POLST and insurance info and notify family.

*Usually the nurse would call the hospital and talk with EMTs but there was no nurse available during this event.

*The  MT should document what information is provided to EMTs.

*R2 is not a reliable historian and was unable to tell EMS or hospital staff what is wrong with her.

*The hospital calls the facility when resident arrives to get background.

These findings were reviewed with and acknowledged by Staff #1 (S1) on 03/09/2023 who was in agreement.

Plan of Correction: RN to provide training to Medication Technicians on change of condition and responding to emergencies within two weeks, reviewing all steps to be taken if a resident needs to be sent out to the hospital.

Based on record review and interview it was confirmed that the facility failed to carry out medication and treatment orders as prescribed. Findings include but not limited to:

During an unannounced site visit on 03/09/2023, Compliance Specialist (CS) reviewed an incident report dated 06/01/2020 which revealed Resident #1 (R1) did not receive doses of medications on 5/28/2020 and 5/29/2020.

During interview, Staff #3 (S3) stated that the facility no longer has on-call medication technician positions and that the MT who committed these errors as well as the Director of Health Services for that time  is no longer employed by the facility.

These findings were reviewed with and acknowledged by Staff #1 (S1) on 03/09/2023 who was in agreement.

Plan of Correction: The facility now reviews a missed-medication report daily. Nurses are auditing medication carts monthly.

Based on observation, interview and record review it was confirmed that the facility failed to fully implement an Acuity-Based Staffing Tool (ABST). Findings include but not limited to:

During an unannounced site visit on 03/09/2023, Compliance Specialist (CS) observed a pink binder, provided by Staff #3 (S3) labeled 'Acuity-Based Staffing."

A review of documents inside of the binder revealed an acuity report, which did not contain any resident names and was dated 12/15/2022.

A review of the facility's ABST for 3/9/2023 did not contain any resident names and revealed the need for:

*72 hours/care on Day shift

*11 hours 10 minutes of care on evening shift

*33 hours 50 minutes of care on noc shift

During interview, Staff #1 (S1) stated:

*The ABST had not be reviewed since December 2022.

*Point Click Care auto-programs times for some tasks that they can not change.

*Staff have had difficulty fixing time required for tasks in service plans, which then effects the ABST.

*Data may not be entered correctly.

During interview Staff #2 explained staffing:

Vlahos

Day: 3 Caregivers (CG) and 1 Medication Technician (MT)

Eve: 2.5 CG, 1 MT

Noc: 1 CG, 1 MT that is shared between Vlahos and Forrest Court

Forrest Court:

Day: 2 CG, 2 MT

Eve: 2 CG, 2 MT

NOC: 1 CG, 1 MT that is shared between Vlahos and Forrest Court

These findings were reviewed with and acknowledged by S1 on 03/09/2023 who was in agreement.

Plan of Correction: Facility stated they will begin reviewing ABST with every new move-in, quarterly update and change of conditions as well as during clinical meeting every Tuesday.