Print Inspection: VCVB

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 9/16/2022.  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 the facility failed to carry out medication and treatment orders as prescribed.  Findings include:

In an interview on 9/16/2022, Staff #1 (S1) reported the following:

*A medication audit by the facility RN showed Resident #1 (R1) went without prescribed medications for 4 days.

*The medication was entered into R1's Medication Administration Record (MAR) as not administered because it had not been received from the pharmacy, when the medication had been entered incorrectly under a different resident's name.

*Record review of the facility's incident report and self report to Adult Protection Services dated 9/7/2022 supported S1's statement.

Record review on 9/16/2022 of Resident #1-2 (R1-2)s MARs revealed the following:

*R1 missed scheduled mediations for 4 days because they were not in the facility.

*R2's MAR reflected the addition of R1's medication in error, however R2 never received the medication.

On 9/16/2022, findings were reviewed and acknowledged by S1.

Plan of Correction:

Facility LPN did an internal investigation into the mixup with medications, several Med Techs were involved.  All received in-service training on receiving and updated medications in MARs.