Print Inspection: R8SM

The findings of the re-licensure survey, conducted  05/02/22 through 05/03/22 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 Home and Community Based Services Regulations OARs 411 Division 004.

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 re-visit survey to the initial survey of  05/03/22, conducted 07/13/22 through 07/14/22, 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.

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

MCC:Memory 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 second re-visit to the re-licensure survey of 05/03/22, conducted 03/23/23, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, and Home and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed when a resident experienced a significant change of condition for 1 of 1 sampled resident (#2). Findings include, but are not limited to:

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

During the acuity interview on 05/03/22, Staff 11 (Director of Nursing Services) stated the resident had experienced a significant weight gain.

Review of the resident's 02/21/22 through 05/03/22 weight records, physician orders and MAR revealed the following:

* On 02/22/22 the resident weighed 219 lbs;

* On 03/25/22 the resident's weight was 236 lbs, which constituted a severe weight gain of 17 lbs or 7.2 % in one month; and

*On 04/07/22, the resident's weight was 246.6, which represented an additional weight gain of 10 lb for a total of 27.6 lbs or a 12.6% weight gain in less than two months.  

During an interview with Witness 1 (Resident 2's Spouse), s/he indicated the resident had lost weight prior to admission, had no edema and attributed the resident's weight gain to steroid medications administered related to his/her cancer treatments.

Physician orders dated 02/21/22 indicated the resident was to be administered dexamethasone (a steroid medication) 8 mg twice daily. Updated physician orders written on 03/03/22 instructed staff to administer 20 mg of the medication once a week. Review of the 04/02/22 through 05/2/22 MAR confirmed the resident was administered the medication as ordered. The side effects of the medication include weight gain.

There was no documented evidence the RN had completed an assessment related to the severe weight gain.

On 5/03/2022, Staff 11 confirmed an assessment had not been completed.

The need to complete an RN assessment when residents' experienced a significant change of condition was discussed with Staff 1 (Campus Administrator) and Staff 11 on 05/02/22. They acknowledged the findings.

RN has completed a significant change assessment on Resident #2 as well as notified the primary care physician.

100% audit of all residents with significant weight changes has been completed.  

HSD has in-serviced all Med Techs in regard to notifications to primary care phyiscian on weight changes.

Marquis RN Consultant has in-serviced HSD in regard to significant change assessments.

Health Services Director or designee will audit all residents with weight changes weekly x4 weeks, then monthly x90 days to ensure ongoing compliance.  Audits to include looking at weights.

Results will be reviewed and discussed as needed at monthly QAA meetings

Based on interview and record review, it was determined the facility failed to ensure RN delegation was completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules Division 47, for 1 of 1 sampled resident (#1) reviewed for the delegation of diabetic injections by unlicensed staff.  Findings include, but are not limited to:

Resident 1 was identified as having non-insulin dependent diabetes and was administered weekly Ozempic injections by non-licensed staff.

On 05/03/22, the facility's RN delegation records were reviewed and revealed the following:

* No documentation of a nursing assessment and condition of the client to determine the resident's condition was stable and predictable;

* Rationale that task can be safely delegated to the caregiver;

* Skills, abilities and willingness of the caregiver to perform the task;

* Frequency the resident should be reassessed including rationale; and

* Frequency the caregiver should be supervised and reevaluated including rationale.

In an interview on 05/03/22, Staff 11 (Director of Nursing Services) stated she had not completed the areas in question but understood they needed to be done with each delegation. Staff 11 indicated only one staff was delegated for the Ozempic injections as they were done weekly, and on a day when Staff 11 was available to administer the injection if delegated staff were unavailable.

The need to ensure RN delegation was completed and maintained as required by OSBN Division 47 was discussed with Staff 1 (Campus Administrator). She acknowledged the findings.

RN to complete new delegation assessment on resident #1 to include; assessment of determination of stability /predictability and frequency of re-assessment needed.  Re-delegation of medication technician to include; competency determined by RN, frequency of delegation.

Marquis Consultant will in-service HSD, RN on delegation.

Marquis Consultant or designee will audit all residents with delegations monthly x90 days. Administrator to sign off on Marquis Consultant's audit each month for 90 days.

Results will be reviewed and discussed as needed at QAA meetings

Based on interview and record review, it was determined the facility failed to ensure the MAR was accurate, included resident specific parameters and instructions for the administration of PRN medications and the initials of the person administering the medication for 1 of 3 sampled residents (#2) whose facility records were reviewed. Findings include, but are not limited to:

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

Review of the resident's 03/16/22 service plan, current physician orders, 04/01/22 through 5/3/22 MARs and interviews with staff revealed the following:

* PRN orders for both acetaminophen and oxycodone for pain lacked parameters related to which medication should be administered first;

* PRN orders for lactulose and Dulcolax suppository for constipation lacked parameters for which medication should be administered first; and

* The service plan noted the resident's medication could be left at bedside. Interviews with Staff 11 (Director of Nursing Services) and Staff 5 (MT) confirmed MT staff left medications with the resident.

The need to ensure PRN medications included resident specific parameters and instructions for the administration of the medications and that the MAR was initialed by the individual who dispensed the medication was discussed with Staff 1 (Campus Administrator) and Staff 11 (Director of Nursing Services) on 05/03/22. They acknowledged the findings.

Resident #2 - Physician PRN orders have been updated to reflect specific parameters for use. RN has completed a new self-medication assessment to determine consistent determination for patient centered medication administration, service plan and physician orders will be updated as indicated based on assessment.

RN to review all medication orders for all current residents in the facility for accuracy including specific parameters, instruction for the administration of PRN.  

RN to in-service RSC and Med Techs on the process of confirming orders after Pharmacy inputs the orders into PCC.  Marquis RN consultant will in-service RN on review of pharmacy integrated orders to ensure specific parameters for use, are included in the medication administration directions.

RN  will audit new orders on all residents ongoing.

Administrator and IDT team will review orders in 24 hr report (Mon-Friday)

Based on interview and record review, it was determined the facility failed to ensure the MAR was accurate and included parameters for the administration of PRN medications for 1 of 1 sampled resident (#4). This is a repeat citation. Findings include, but are not limited to:

Resident 4 was admitted to the facility with diagnoses including trigeminal neuralgia.

Review of the 07/02/22 through 07/13/22 MAR and the 06/24/22 signed physician orders revealed the following:

A signed physician order, dated 06/24/22, instructed the facility to administer 1-2 tablets of acetaminophen PRN for pain.  There were no parameters identified on the MAR which instructed unlicensed staff when to administer one versus two tablets.

Resident 4 was administered the medication on 07/02/22, 07/03/22, 07/05/22, and 07/06/22. There was no documentation on the MAR how many tablets were administered to the resident.

The need to ensure the MAR was accurate and included parameters for the administration of PRN medications was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 07/14/22. They acknowledged the findings.

Resident ID #4 - Physician PRN orders have been updated to reflect specific parameters for use.  

RN to review all PRN medication orders for all current residents in the facility for accuracy including specific parameters.  

RN to in-service RSC and Med Techs on the process of confirming orders after Pharmacy inputs the orders into PCC.

RN  will audit new orders on all residents ongoing.

Administrator and IDT team will review orders in 24 hr report (Mon-Friday)

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 02/22/22 and Staff 13 (CG/MT) hired 02/22/22 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 1 (Campus Administrator) and Staff 11 (Director of Nursing Services) on 05/03/22. They acknowledge the findings.

Staff #7, #8 and #13 have completed 30 day competency training in the following areas Role of service plans in providing indivdiualized care; providing assistance with ADLs; changes associated with normal aging; Identifications, 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 training needs in this area will have in-services completed

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

Administrator in-serviced the Resident Services Coordinator and Human Resources 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 x 4 weeks, then monthly x 90 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 interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:

Refer to C 310.

Refer to POC for C310