Print Inspection: KNDE

The findings of the on-site investigation, conducted 05/22/23, 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 observation, interview and record review during a site visit on 05/22/23, it was confirmed the facility failed to ensure service plans were reflective of the resident's current status and care needs and provided clear instructions for care staff regarding the delivery of services for 2 of 3 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was observed to ambulate with a walker, had long finger nails and appeared to be clean.

In an interview with Resident 1, s/he stated the facility was not providing Epsom salt foot soaks or toenail care. Resident 1 stated, that he was seeing a home health RN the date of the site visit to view his/her toenails.

Resident 1's current service plan dated 03/02/23, noted the resident was to have his/her feet monitored daily, and did not provide clear direction to staff on who would provide toenail care.

The need to ensure service plans were reflective of residents current status and provided clear direction to staff related to the provision of care regarding toenail care was discussed with Staff 1 (Administrator) on 05/22/23. S/he acknowledged the findings.

The facility failed to provide clear directions to staff on Resident 1's toenail care.

Facility Verbal Plan of Correction:

The facility will review and update Resident 1's service plans to ensure it's reflective of the resident current care needs.

2. During the site visit Resident 2 was observed in bed.

Resident 2's service plan, dated 03/06/23 noted the resident was "mostly" bed bound. The service plan was not reflective of the resident's current status nor did it provide clear direction to staff in the following areas:

* The level of assistance needed with bathing, grooming, dressing, oral care, housekeeping and transfers;

* Assistive/adaptive devices needed; and

* Activity preferences and accommodations needed to participate.

Progress notes for Resident 2, dated 04/10/23 through 05/20/23, were reviewed. On 04/27/23, the facility nurse instructed staff to reposition the resident at least every two hours to prevent further skin breakdown.

During an interview on 05/22/23, Staff 4 (CG) stated Resident 2 received assistance in the morning with waking, washing eyes, getting up to receive breakfast and water, then the resident goes back to bed.

The need to ensure service plans were reflective of residents current status and provided clear direction to staff related to the provision of care was discussed with Staff 1 (Administrator) on 05/22/23. S/he acknowledged the findings.

The facility failed to provide clear directions to staff on Resident 2's ADL care.

Facility Verbal Plan of Correction:

The facility will review and update Resident 2's service plans to ensure it's reflective of the resident current care needs.

3. During the site visit on 5/22/23, residents were not observed to be left in bed all day.

Based on observation, interview and record review during a site visit on 05/22/23, it was confirmed that the facility failed to evaluate changes of condition, determine resident-specific actions or interventions, provide written communication of those interventions to staff on each shift,  and monitor the condition to resolution for 1 of 2 sampled residents (# 1) who experienced changes of condition. Findings include, but are not limited to:

Resident 1 was observed to be alert and oriented and ambulate around the facility.

During an interview with the resident, s/he stated they had foot pain.  

Resident 1's current service plan, dated 03/02/23, progress notes from 04/2023  through 5/22/23, and MARs from  04/2023 through 05/22/23, were reviewed. Resident 1's records revealed s/he experienced a significant change of condition related to increased pain.

The MAR, noted on 04/24/23 the resident requested PRN pain medication consistently and from 04/24/23 - 05/22/23 the resident requested pain medication 32 time due to increased pain.

There was no documented evaluation regarding the resident increase in pain, no intervention put in place or a referral to the RN for the resident's change of condition.

The need to ensure a system for documenting and monitoring changes of condition through resolution and communicating changes and interventions to staff was discussed with Staff 1 (Administrator) 05/23/23. She acknowledged the findings.

The facility failed to evaluate resident after a change of condition.

Facility Verbal Plan of Correction

The administrator, facility nurse, and/or resident care coordinator will be responsible to monitor Resident 1's care and ensure that any significant change of conditions are evaluated timely.

Based on interview and record review during a site visit on 05/22/23, it was confirmed that the facility failed to ensure physician orders were carried out as prescribed for 2 of 3 sampled residents (#s 1 and 3) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 1's clinical records noted an order, dated 03/10/23 to receive gabapentin one capsule three times a day for diabetic neuropathic pain.

Review of Resident 1's 04/2023 through 05/22/23 MAR revealed the resident was receiving the medication two time a day instead of the ordered three times a day.

In an interview on 05/22/23, Resident 1 stated s/he had arthritis in his/her feet causing pain.

In an interview on 05/22/23, Staff 3 (RCC) stated there was a new order for Resident 1's gabapentin to be administered twice a day.

Facility was unable to find documentation of corrected or updated order.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 05/22/23.

The facility failed to administer Resident 1's medication as prescribed.

2. Resident 3's clinical records noted an order, dated 03/30/23 for sennosides docusate sodium two tablets by mouth twice a day.

Resident 3's 04/2023 MAR noted on 04/15/23 at 5 pm the medication was not available and on 04/19/23 medication not reordered, "will reorder today".

In an interview on 05/22/23, Staff 3 (RCC) stated the facility relies on the family to provide Resident 3's over-the-counter medications. Staff 3 further stated they were attempting to get the medication from the family prior to running out.

Facility was unable to provide documented evidence of correspondence with family or the attempts made to fill the prescription before the resident's medication ran out.

The findings were reviewed with Staff 1 (Administrator) on 05/22/23. S/he acknowledged the findings.

The facility failed to administer Resident 3's medication as prescribed.

Facility Verbal Plan of Correction:

The physician's orders will be sent to the prescriber for review routinely every 90 days to ensure that all medications are being carried out as prescribed. The administrator, facility nurse, and/or resident care coordinator will be responsible in monitoring that system.