Print Inspection: N16F

The findings of the onsite investigation, conducted 11/02/23 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

bid:twice a day

CBG:capillary blood glucose or

blood sugar

cc:cubic centimeter

CG:caregiver

cm:centimeter

F:Fahrenheit

HH:Home Health

HS or hs:hour of sleep

LPN:Licensed Practical Nurse

MA:Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

O2 sats:oxygen saturation in the

blood

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

RN:Registered Nurse

SP:service plan

TAR:Treatment Administration

Record

tid:three times a day

Based on interview and record review, conducted during a site visit on 11/02/23, it was determined the facility failed to ensure a system for tracking of controlled substances for 3 of 3 sampled residents (#s 1, 2, and 3). Findings include, but are not limited to:

In separate interviews, Staff 2 (MT), Staff 10 (MT), Staff 19 (MT), and Staff 21 (MT) stated the following:

* If a medication error occurs, MTs are to document the error, report to the nurse, and start a temporary service plan (TSP), and monitor the resident.

* When a narcotic medication is administered, MT must read the order, read the medication card, read the MAR to confirm it's the correct medication, pop the medication, then document in the Narcotic Book. After administering the medication the MT must confirm the administration in the MAR.

* Two MTs are required to count each narcotic card for each resident at shift change, in which the oncoming MT counts out with the MT at the end of their shift.

* If a narcotic has to be destroyed, it's one MT and the nurse for a total of two staff to witness.

A review of the Resident 1, 2 and 3's clinical records and facility records including the Narcotic Tracking Book, 24-hour communication logs, dated 11/2023, and the policy and procedures for tracking of controlled substances were reviewed during the site visit.

a. A review of Resident 1's MAR, dated 10/01/23 through 10/31/23, progress notes, dated 10/06/23 through 10/28/23, and facility's narcotic tracking record indicated the following:

* Resident 1 had been prescribed "alprazolam 1 tablet by mouth every night at bedtime."

* On 10/25/23 and 10/31/23, staff initialed as having administered the medication on the MAR, however the two doses had not been singed out on the dispostion log.

b. A review of Resident 2's MAR, dated 10/01/23 through 10/31/23, progress notes, dated 10/03/23 through 11/02/23, and facility's narcotic tracking record indicated the following:

* Resident 2 had been prescribed "morphine sulfate 20 mg/ml SOLN, 0.5ML (10 mg) by mouth every hour as needed for pain or SOB".

* On 10/26/23, his/her MAR indicated morphine was administered twice at 7:32 am and 8:05 pm. The narcotic disposition log indicated the medication had been dispensed at 8:00 am, 10:30 am, and 8:00 pm.

* Resident 2 had been prescribed "Tramadol, 1 tablet (50 mg) by mouth every 2 hours as needed for pain levels 5 or 6 out of 10".

* On 10/29/23, his/her MAR indicated Tramadol was administered once at 3:24 am. The narcotic disposition log indicated the medication had been dispensed twice, at 3:25 am and 9:23 am.

* On 10/22/23, his/her MAR indicated Tramadol was administered once at 1:22 pm. The narcotic disposition log indicated the medication had been dispensed twice, at 3:24 (no indication am or pm) and 7:00 am. The 1:22 pm dose was not recorded in the disposition log.

* Narcotic Tracking Book indicated tramadol was dispensed once on 10/13/23 and 10/15/23. There was no documentation on the MAR to indicate the medication had been administered on those dates.

* On 10/21/23, his/her MAR indicated tramadol was administered twice at 9:36 pm and 10:18 pm. The 10:18 pm dose was not recorded in the disposition log.

*On 10/01/23, 10/02/23, 10/05/23, 10/06/23, 10/08/23, 10/10/23, and 10/11/23, the MAR indicated tramadol was administered at 1:28 pm, 12:35 am, 3:20 am, 1:40 am, 3:55 am, 4:13 pm, and 11:33 am respectively. There was no evidence to indicated the medication administered on these days and times were documented in the Narcotic Tracking Book.

c. A review of Resident 3's MAR, dated 10/01/23 through 11/02/23, progress notes, dated 10/05/23 through 11/01/23, and facility's narcotic tracking record indicated the following:

* Resident 3 was prescribed "oxycodone 5MG tab, 2 tablets (10mg) by mouth at bedtime as needed for pain" and "oxycodone 5MG tab, 1 tablet by mouth 4 hours later as needed for 28 days."

* On 10/22/23, Narcotic Tracking Book indicated 1 tablet of oxycodone was dispensed at "11:30". There was no evidence to indicate oxycodone had been administered on Resident 2's MAR.

* On 10/27/23, his/her MAR indicated 1 tablet of oxycodone was administered twice at 1:04 am and 11:04 pm.

* Narcotic Tracking Book indicated oxycodone was administered only on one occasion on 10/27/23 at "0100". There was no evidence to indicate the 11:04 pm administration of this medication was documented in Narcotic Tracking Book.

The facility failed to ensure a system for tracking of controlled substances.

On 11/02/23, the findings related to Resident 2's morphine on 10/26/23 and the importance of maintaining accurate records were reviewed with and acknowledged by Staff 22 (RN), Staff 23 (Contracted Nurse), and Staff 3 (BOM).

On 11/15/23, via telephone the additional findings were attempted to be reviewed with Staff 1 (Administrator). Staff 1 stated this was outside his/her scope and the regional nurse would call to review.

Based on interview and record review, conducted during a site visit on 11/02/23, it was confirmed the facility failed to carry out medication or treatment orders as prescribed for 1 of 1 sampled resident (#1) whose MAR was reviewed. Findings include, but are not limited to:

A review of Resident 1's records including Medication Administration Record, dated 10/01/23 through 10/31/23, physician orders, chart notes, dated 10/01/23 through 10/31/23 and service plan, dated 08/08/23, indicated the following:

* Morphine (for pain) 15 mg tab, 1 tablet by mouth twice daily at 8:00 a.m. and 3:00 p.m.

* Morphine (for pain) 30 mg tab, 1 tablet by mouth twice daily, take in the morning and at bedtime, 10:00 a.m. and 9:00 p.m.

* On 10/07/23, Resident 1 received 15 mg of [pain medication] at 10:00 am instead of 30 mg as ordered.

* On 10/25/23, there was no evidence to indicate that 5 medications scheduled for 4:00 p.m. were administered.

In an interview, Resident 1 stated s/he had no complaints.

In separate interviews, Staff 2 (Medication Technician), Staff 10 (Medication Technician), Staff 19 (Medication Technician), and Staff 21 (Medication Technician) stated when a medication error occurred staff were to document the error, report error to the nurse, start a temporary service plan to monitor for adverse effects.

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

On 11/02/23, these findings were reviewed with and acknowledged by Staff 22 (RN), Staff 23 (Contracted Nurse), and Staff 3 (BOM). Staff 3 stated the possible reason for the missed medications on 10/25/23 was due to the internet going out.

Verbal Plan of Correction:

Within two weeks, the nurse will provide Medication Technicians training, and implement a self-MT audit using the electronic MAR dashboard in which MT will sign off as all medications have been administered, and the nurse will perform weekly audits.

Based on observation and interview, conducted during a site visit on 11/02/23, it was confirmed the  facility failed to keep all interior materials (e.g. floors) clean and in good repair for 1 of 1 sampled resident (#4). Findings include, but are not limited to:

At 1:30 pm, the Compliance Specialist observed Resident 4's living room carpet to have multiple black spots and yellow and red stains near Resident 4's dining table.

In an interview Resident 4 stated housekeepers clean apartment on Wednesdays and another day of the week. Housekeepers vacuum, mop, does dishes, clean and sanitizes, and washes clothes and linens weekly.

In separate interviews Staff 14 and Staff 16 stated shampooing of carpet is not a regular housekeeping service.

The facility failed to keep all interior material (e.g. floors) clean.

On 11/02/23, these findings were reviewed with and acknowledged by Staff 22 (RN), Staff 23 (Contracted Nurse), and Staff 3 (BOM).

Verbal Plan of Correction:

Within 1 week, the facility will shampoo Resident 4's carpet and has started to receive bids to replace carpet in response to re-licensing survey findings.