Print Inspection: NRTF

The findings of the re-licensure survey, conducted 05/02/22 through 05/04/22, 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

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 re-visit to the initial survey of 05/04/22, conducted 07/13/22, 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 and OARs 411 Division 004 for Home and Community Based Services Regulations. The facility was found to be in substantial compliance with the regulations.

Based on interview and record review, it was determined the facility failed to ensure that actions and interventions were determined, documented, communicated to staff on all shifts and the resident monitored based on his or her evaluated needs for 1 of 2 sampled residents (#2) who experienced short-term changes of condition. Findings include, but are not limited to:

Resident 2 was admitted to the facility in February 2022 with diagnoses including dementia.

The resident's 01/29/22 service plan, 02/01/22 through 05/03/22 progress notes and current physician orders were reviewed.

The facility failed to determine and document actions and interventions needed for the resident, communicate interventions to staff and monitor short term changes in condition at least weekly to resolution in the following areas:

* Emergency room visits;

* Tremors; and

* Medication Changes.

The need to ensure that actions and interventions were determined, documented and communicated to staff and the resident's condition was monitored to resolution was discussed with Staff 17 (MC Administrator) and Staff 11 (Health Services Director/RN) on 05/04/22. They acknowledged the findings.

Resident #2 RN assessment completed of current status addressing; Emergency Room visits, tremors and recent medication changes. Weekly assessments not indicated.

All residents who experience a short term change of condition are potentially impacted.

100% Audit completed on all residents over last 30 days to identify if any short term change of condition assessments are indicated.

RN HSD will provide in-service to all direct care staff on Change of Condition Policy and Alert charting process.

RN HSD will review ongoing for short term change of conditions, charting and indicators for RN weekly assessments per policy.

Administrator will audit weekly x4 weeks during 24hour report for alert charting by care staff and RN weekly assessments, as indicated.

Results of audits will be reviewed as part of the facility QAA meetings.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled residents (#1) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to:

Resident 1 was admitted to the facility in April 2022 with diagnoses including dementia, abdominal pain and anxiety.

Resident 1's signed physician orders, dated 04/07/22 included the following orders:

* Lorazepam 0.5 mg tablet, give 0.5 tab (0.25 mg) by mouth three times a day PRN for anxiety/agitation unmanageable with non-drug interventions. If PRN not effective within one hour may administer second 0.5 tab (0.25 mg).  

Resident 1's Controlled Substance Disposition logs and MARS, for 04/07/22-05/02/22 showed the following:

* On 04/09/22, 04/16/22, 04/21/22 and 04/30/22 doses of Lorazepam were recorded on the disposition log but not on the MAR; and

* On 04/21/22 one dose of Lorazepam was signed out on the disposition log at 5:25 pm but was not signed as given on the MAR until 7:25 pm.

Comparison of the medication dosing cards showed the amount of medication left was reflected accurately on the logs.

The need to ensure narcotic disposition logs and MARs were accurate and medications were recorded appropriately was discussed with Staff 17 (MC Administrator) on 05/04/22. No additional documentation was provided, the staff acknowledged the findings.

Review completed by HSD of Resident #2's Controlled substance orders/administration record and disposition log.

All residents with controlled medicaitons potentially impacted

HSD or designee will provide in-servicing to Medication Technicians on on EMAR and Narcotic record documentation accuracy.

HSD or designee will review 100% Residents with Narcotic medication administration for accuracy of disposition log compared to EMAR weekly for four weeks and monthly x90 days

.

Results of Audits will be reviewed as part of our facility QAA Meetings.

Based on interview and record review, it was revealed the facility failed to ensure that 3 of 3 newly hired staff (#s 7, 8 and 13) demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to:

Review of staff training records on 05/03/22 revealed Staff 7 (CG/MT) hired 01/11/22, Staff 8 (CG/MT) hired 02/02/22 and Staff 13 (CG/MT) hired 02/02/22 lacked documented evidence of competency within 30 days of hire in the following required areas:

* Roll of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition; and

* Duties of the medication technician.

The need to ensure competency was determined in all required areas within 30 days of hire was discussed with Staff 17 (MC Administrator) and Staff 11 (Health Services Director/RN) on 05/04/22. They acknowledged the findings.

Staff #7, #8 and #13 have completed 30 day competency training in the following areas: Role of service plans in providing individualized care; providing assistance with ADLs; changes associated with normal aging; Identification, documentation and reporting of changes of condition; and duties of the medication technician.

100% Audit of all current employees has been completed to ensure compliance with competency trainings listed above within 30 days of hire.

Staff identified with needs in this area will be in-serviced by RSC

.

Administrator has inserviced all facility staff on the training requirements of upon hire training.

Administrator in-serviced the RSC and HR on the process for new hire 30 day competency training, including ongoing tracking of all employees.

Administrator or designee will audit all new employees weekly x4 weeks, then monthly x90 days to ensure ongoing compliance.

Audits to include compliance with competency training within 30 days of hire.

Results of these audits to be reviewed at facility QAA meetings.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C270 and C302.

Refer to C270 and C302