Print Inspection: MNY0

The findings of the re-licensure survey, conducted 02/06/23 through 02/09/23, 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, OARs 411 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

MCCMemory 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 revisit to the re-licensure survey of 02/09/23, conducted on 05/11/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 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 1 of 1 sampled resident (#3) who had documented medication refusals. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 11/2021 with diagnosis's including Ocular Hypertension and Vitreous hemorrhage of Right eye. Resident 3's clinical records and MARs/TARs were reviewed.

Resident 3 had signed physician orders to administer Carboxymethyl 0.5% solution four times daily into the right eye. The MAR indicated the resident refused the medication on four occasions from 01/1/23 through 02/06/23.

A physician order to "Notify MD each time resident refuses medication(s) or treatment(s)" was included in Resident 3's chart. There was no documented evidence the facility had notified the physician after each refusal.

On 02/08/23, the need to ensure the facility notified the physician when a resident refused medications or treatments was discussed with Staff 1 (Health Services Director), Staff 2 (RCC), and Staff 5 (Regional RN). They acknowledged the findings.

Med Techs re-trained on Medication Refusal Policy & Protocol on 02/15/2023.

RCC will review the "Medication Exception Report" generated by QuickMAR on each work day for one month and as needed ongoing. During review, RCC will ensure Frontier Policy is being followed for any variance/refusal.

HSD will then audit "Medication Exception Report" monthly for 3 months and as needed ongoing.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications ordered by a legal prescriber and administered by the facility, for 4 of 4 sampled residents (#s 1, 2, 3 and 5) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 1's MAR, dated 01/01/23 through 02/06/23, and current physician orders were reviewed during survey. The following were identified:

*The MAR listed acetaminophen and morphine as PRN pain medications. There was no clear instruction regarding the sequential order of administration for these medications; and

*The MAR lacked clear instruction on the sequential order of use for haloperidol and Lorazepam, two PRN medications for anxiety.

2. Resident 2's MAR, dated 01/01/23 through 02/06/23, and current physician orders were reviewed during survey. The following deficiencies were identified:

The MAR included the following three PRN pain medications: acetaminophen, diclofenac sodium, and methyl s/menth/cam. There were no instructions on the sequential order of use for these medications.

On 02/09/23, the need to ensure resident MARs were accurate and included specific instructions to staff was discussed with Staff 1 (Health Services Director), Staff 2 (RCC) and Staff 5 (Regional RN). They acknowledged the findings. No further information was provided.

3. Residents 3's physician orders and MARs were reviewed from 01/01/23 through 02/06/23 and revealed the following:

*Resident was prescribed PRN Acetaminophen 500 mg by mouth three times a day for pain, and Ibuprofen 200 mg by mouth two times a day for pain. There were no directions for unlicensed staff which pain medication to administer first.

*Resident was prescribed 1-2 drops of Carboxymethyl 0.5% solution four times daily into the right eye. There were no specific directions for unlicensed staff to apply 1 or 2 drops into the residents right eye.

On 02/08/23, the need to ensure there were clear parameters for unlicensed staff when administering medications was discussed with Staff 1 (Health Services Director), Staff 2 (RCC), and Staff 5 (Regional RN). They acknowledged the findings.

4. Residents 5's physician orders and MARs were reviewed from 01/01/23 through 02/06/23 and revealed the following:

*Resident was prescribed 5 to 10 drops of Carbamide 6.5% solution two times daily into ear canal as needed. There were no specific directions for unlicensed staff on how many drops to apply.

*Resident was prescribed 1 to 5 drops of Suavear 6.5% (Carbamide Peroxide) two times daily into both ears as needed. There were no specific directions for unlicensed staff on how many drops to apply.

On 02/08/23, the need to ensure there were clear parameters for unlicensed staff when administering medications was discussed with Staff 1 (Health Services Director), Staff 2 (RCC), and Staff 5 (Regional RN). They acknowledged the findings.

Those 3 MARS were updated with proper instructions as to which PRN to use first, as well as instructive information Med Techs should have such as allow 10 minutes between eye drops if multiple prescriptions given.

All MARS audited and updated with proper instructions as to which PRN to use first, as well as any other instructive information Med Techs should have such as allow 10 minutes between eye drops if multiple prescriptions given.

Med Techs re-trained to expect these instructions in physician orders on 02/15/2023 during meeting.

HSD will add in MAR any instructions needed for Med Techs during 3rd order transcription check.

HSD/RCC/ED or other assigned person will audit MAR's monthly for 3 months and as needed ongoing to ensure the proper instruction exists.

Based on interview and record review, it was determined the facility failed to provide documentation fire drills were being conducted every other month, fire drills included all required components, and staff were trained in fire and life safety on alternating months of the fire drills. Findings include, but are not limited to:

Fire and life safety records from 07/2022 through 01/2023 were reviewed during the survey. The following deficiencies were identified:

*Fire drills were not consistently being conducted every other month;

*Fire and life safety instruction was not consistently being conducted on alternating months of fire drills;

*Documentation of the fire drills lacked inclusion of all required components, such as escape routes used, number of occupants evacuated, and evacuation time period needed; and

*There was no documented evidence the facility used alternate escape routes during fire drills.

On 02/07/23, the need to ensure the facility was conducting fire drills every other month, documented all required fire drill components, and provided fire and life safety instruction to staff on alternating months of the fire drills was discussed with Staff 4 (Environmental Services Director) and Staff 5 (Regional RN). They acknowledged the findings.

Fire and Life Safety Training Calendar was created for monthly assignments to ensure rule is followed. Training calendar alternates fire drills with disaster plan review.

ESD will complete drills/trainings by end of month according to Training Calendar.

ED will ensure ESD has completed drill/training per Training Calendar.

Fire Drill logs and disaster inservice training logs will be stored in Fire and Life Safety Binder located in ED office.

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 provide security and to alert staff when residents exited the building. Findings include, but are not limited to:

During the survey, the exit doors from the ALF to the outside courtyard failed to have a working alarm or other acceptable system to alert staff when residents exited the building.

On 02/07/23, the lack of alarms on exit doors or other acceptable system to alert staff was discussed with Staff 4 (Environmental Services Director) and Staff 5 (Regional RN). They acknowledged the findings.

Door alarms ordered by ED on 02/13/23.

Alarms will be installed by ESD upon receipt.

Door alarms will be programmed to sound with Ciscor Nurse Call System as other exterior doors alarm.

Staff will complete visual checks upon hearing Ciscor Nurse Call System alert.