Print Inspection: E013

The findings of the on-site investigation, conducted 07/11/23 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Abbreviations possibly used in this document:

ADL:activities of daily living

CBG:capillary blood glucose or blood sugar

CG:caregiver

CS: Compliance Specialist

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MT:            Medication Tech

MAR:Medication Administration Record

MCC:Memory Care Community

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

RCC:Resident Care Coordinator

RN:Registered Nurse

Based on interview and record review, conducted during a site visit on 07/11/23, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled residents (#1). Findings include, but not limited to:

Resident 1's signed physician orders, dated 12/01/22 revealed the resident had an order for calcium carbonate 500 mg 1 tab by mouth two times a day with meals.

Resident 1's progress notes for 06/01/23 through 06/30/23 revealed the family brought in calcium citrate 500 mg and s/he received that medication from 05/30/23 through 06/07/23.

During an interview, Staff 1 (Executive Director) stated Resident 1's family brought the medication in as it was less expensive for them to get at the store, than it was through the facility's pharmacy. Staff 1 stated, the wrong supplement was administered unnoticed for several days.

The findings were reviewed with and acknowledged by Staff 1 on 07/11/23.

It was confirmed the facility failed to carry out medication and treatment orders as prescribed.

Verbal plan of correction: Staff 1 to provide education to staff when a medication was received on creating a progress note to document medication name, dose, and verifying medication matches order when receiving a medication from a resident's family member. Staff 1 and nurse will observe all MTs complete a med pass one time per week beginning within the next 30 days to provide any needed education, and audit for skills.

Based on interview and record review, conducted during a site visit on 07/11/23, it was confirmed the facility failed to document orders in the resident's record for all medications and that the facility is responsible to administer for 1 of 1 sampled resident (#2). Findings include, but not limited to:

During interview on 07/11/2022, Staff 1 (Executive Director) stated Resident 2's hospice nurse was in facility on 05/24/23 and discussed a change in Resident 2's narcotic pain medication. Staff 1 further stated Hospice sent the medication, it was entered into the narcotic book. Staff 1 further stated MTs were doing the shift end count on it daily however, staff did not give the medication and did not follow up to request an order for it.

A review of Resident 2's signed physician orders noted the narcotic pain medication was ordered by the hospice RN on 05/24/23 and signed by the provider on 05/30/23. There was no documented evidence the medication was given from 05/24/23 to 06/02/23 or that facility staff attempted to contact hospice to get an order.

The findings were reviewed with and acknowledged by Staff 1 by phone on 07/25/23.

The facility failed to document orders in the resident's facility record for that pain medication the facility is responsible to administer.

Plan of correction: Staff 1 completed a role play/in-service with all MTs on what they would do in that situation. Executive Director to provide education to staff when a medication is received on creating a progress note to document medication name, dose, etc and verifying medication matches order. Staff 1 and nurse would observe all MTs complete a med pass one time per week beginning within the next 30 days to provide any needed education and audit for skills.

Based on interview, and record review, conducted during a site visit on 07/11/23,  it was confirmed the facility failed to carry out medication orders as prescribed for 3 of 3 sampled residents (#s 3, 4 and 5). Findings include, but not limited to:

1. A review of Resident 3's March 2023 MAR indicated Resident 3 had an order for psychoactive medication : Take 1 tab by mouth nightly. A review of the narcotic sign out sheet revealed a dose of that medication was noted to be missing on 3/19/23.

During an interview on 07/11/23, Staff 2 (RN) stated swing shift MT gave Resident 3 their 10:00 pm medication on 03/19/23. Staff 2 stated resident 3 forgot and asked Staff 5 (MT) for it on night shift. Staff 5 gave Resident 3 another dose of psychotropic medication without checking if that medication was already administered.

2. A review of Resident 4's June 2023 MAR indicated Resident 4 had an order for pain medication take two tablets by mouth every six hours as needed.

In an interview on 07/11/23 Staff 2 stated on 06/07/23, Resident 4 asked Staff 5 for one pain pill instead of the ordered two and Staff 5 gave him/her one, not realizing they could not halve the dose.

3. A review of Resident 5's May 2023 MAR revealed resident 5 had an order for pain medication take 1 tab three times by mouth at 10:00 am, 4:00 pm and 10:00 pm as well as an order for pain medication take 1 tab by mouth nightly at 2:00 am.

In an interview on 07/11/23, Staff 2 stated Swing MT gave Resident 5 his/her 10:00 pm pain medication on 05/09/23. Resident 5 didn't remember and asked Staff 5 for it on night shift. Staff 5 gave another 10:00pm dose and then held the 2:00 am dose without consulting anyone.

Staff 1 (Executive Director) and Staff 2 said that Staff 5 was removed from the medication cart after multiple attempts to re-educate. S/he resigned after being removed from the med cart and was no longer employed by the facility.

The findings were reviewed with and acknowledged by Staff 1 and 2 on 07/11/23.

It was confirmed the facility failed to carry out medication orders as prescribed.

Verbal plan of correction:  Staff 1  and Staff 2 will observe all MTs complete a med pass one time per week beginning within the next 30 days to provide any needed education and audit for skills. MT responsible for those errors was removed from the med cart and resigned from his/her position and was no longer employed by the company.

Based on interview and record review, it was confirmed the facility failed to meet the staffing hours needed according to the acuity-based staffing tool (ABST). Findings include, but not limited to:

A review of the facility's ABST revealed four days of the previous week were short of their ABST needs:

On 07/08/23, the facilities staffing hours needed were 87.56, and the facility was staffed with 74.26 hours;

On 07/07/23, the facilities staffing hours needed were 87.56, and the facility was staffed with 62.10 hours;

On 07/05/23, the facilities staffing hours needed were 87.36; and the facility was staffed with 85.22 hours; and

On 07/04/23, the facilities staffing hours needed were 87.36, and the facility was staffed 82.65.

During interview, Staff 1 (Executive Director) stated, they do occasionally have problems with staffing.

The findings were reviewed with and acknowledged by Staff 1 on 07/11/23.

It was confirmed the facility failed to meet the staffing hours needed according the ABST.

Facility plan of correction: Staff 1 stated, she was attempting to recruit and hire new staff. Staff 1 stated, she would educate the business office manager to verify all hours worked when doing the daily ABST verification.