Print Inspection: RR5K

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 12/01/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified:

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 it was confirmed that the facility administrator failed to be responsible for ensuring adequate professional oversight of the medication and treatment system. Findings include the following:

During an unannounced site visit on 12/01/2022 Compliance Specialist (CS) reviewed facility document Medication Error #1861 dated 10/04/2022 which indicated that a residents liquid morphine was empty when according to the narcotics log there still should have been solution remaining. Medication was stored in a bag and the cap was missing, the storage bag was saturated with liquid. According to progress note dated 10/04/2022 for Resident #1 (R1) and Medication Error document, 10/02/2022 was the last time medication was administered at that time the medication was administered by a med tech in training whose trainer stated that the bottle spills sometimes.

In an interview with Staff #1 (S1) it was stated that when the error was found they pulled the med tech from the medication cart, completed an audit of the med carts and completed retraining for all the med techs.

Facility Plan of Correction:

Facility completed training for all med techs on 10/19/2022 to ensure they know proper storage for medications and how to report missing or lost caps for medications.