Print Inspection: YRE6

The findings of the re-licensure survey conducted 01/30/23 through 02/01/23 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

Based on observation, interview and record review, it was determined the facility failed to determine and document actions or interventions needed for residents who experienced changes of condition, communicate the interventions to staff on each shift and document in the resident record with weekly progress noted until the condition resolved for 1 of 2 sampled residents (# 4) who experienced changes of condition. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 02/2018 with diagnoses including Parkinson's disease.

Observations of Resident 4 throughout the survey confirmed the resident was often restless, had difficulty with transfers or walking without assistance and was dependent on staff for most ADLs. The resident's room was located in an area where staff could provide frequent observations. The apartment door was open during day shift hours, and staff provided frequent checks throughout the day.

Clinical records, including the service plan, temporary service plans (TSPs), incident reports, hospice provider notes and charting notes were reviewed. The clinical record provided the following information:

a. Resident 4 experienced ten falls between 11/27/22 and 01/30/23. On 01/15/23, Resident 4 sustained a laceration to his/her head after a fall and required a visit to the emergency department and staples to the laceration.

The record documented information on the falls, how the injury occurred, treatment provided and that the resident was placed on alert monitoring following each fall.

The current service plan, dated 01/16/23, identified fall risks and the following interventions:

* frequent safety checks throughout the day;

* offer toileting assistance every two hours; and

* use of a call pendant.

During an interview on 01/31/23, Staff 1 (Administrator) and Staff 2 (RN) shared information on the resident's fall history, recent decline related to progression of Parkinson's disease and interventions used to address falls, including the strategic location of the resident's room to allow staff close supervision, two transfer poles in the room and keeping the apartment door open for frequent observation; however, these interventions were not on the current service plan.

In addition, there was no evidence the interventions had been communicated to staff on all shifts and were being monitored for effectiveness.

b. Resident 4 had skin injuries that included the following:

* 12/07/22: wound to left buttock; and

* 01/15/23: laceration to head with staples.

The skin injuries represented short-term changes of condition. The skin injuries were identified and documented in the charting notes; however, the record lacked documented evidence interventions were developed if needed. Additionally, the facility staff failed to monitor the skin issues, at least weekly, until the injuries resolved.

The need to ensure the process of documentation of changes of condition included interventions developed as needed, were communicated to staff and monitored, at least weekly until resolved was discussed with Staff 1 and Staff 2 on 01/31/23 and 02/01/23. They acknowledged the findings.

1) Actions taken to correct the rule violation are as follows:

a.The RN will monitor all resident changes in condition until resolved and will document weekly.

b.The RN will include any interventions developed as needed and communicate them to the staff.

2) The system for communicating a resident's change in condition to care staff will be reviewed with all staff to ensure that facility policies and procedures on documenting resident changes in condition will be followed.  The Administrator will follow up with RN to ensure changes in condition are being assessed ad monitored, as needed.

Communication tools include the shift-to-shift report, TSPs, Care Plans, and alert charting notes, as well as verbal communication when possible.

3)The Administrator, RN, and/or RCC will review the shift-to-shift report and chart notes daily. When a change in condition is noted they will ensure that all policies and procedures are being followed.  

3) Any time there is a change in condition the RN will assess the resident and monitor the change of condition and document in the chart notes weekly, or more often, as needed, until the situation is rresolved. The RN will update the TSP as needed to address changes during the monitoring process related to the change in condition and will direct staff on what to monitor for, how to provide care, and what to report as a concern.

4) The Administrator will be responsible for ensuring that all resident change in condition monitoring is completed weekly or more often as needed, and that progress is documented in the chart notes.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment included documented findings, resident status and interventions made as a result of the assessment for 1 of 1 sampled resident (# 4) who experienced a significant change of condition. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 02/2018 with diagnoses including Parkinson's disease. The resident had experienced a decrease in overall functioning, increased frequency of falls and a head injury.

An RN assessment was completed on 01/16/23 following the resident's return from the emergency department related to a fall with head laceration.

The assessment lacked information related to the resident's recent falls, head injury and overall decline in ADL functioning. In addition, the assessment failed to document required information, including findings, resident status and interventions made as a result of the assessment.

The need to ensure an RN assessment included all required information was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 02/01/23. They acknowledged the findings.

1) Action taken to correct the rule violation includes:

The RN will receive additional training on how to complete a thorough assessment when a resident has experienced a change in condition. She has received training on how to document the details of her assessment in the chart notes. Interventions that have been put in place will be included in the care plan, TSP, and chart notes.

2) When a significant change in condition occurs the RN will be notified and will then complete an assessment and implement interventions, as needed. The Care Plan, TSP, and chart notes will be updated to reflect any interventions.

3) The Administrator, RN, and/or RCC will review the shift-to-shift report and chart notes daily. When a change in condition is noted they will ensure that all policies and procedures are being followed.  

4) The Administrator will be responsible for seeing that all monitoring of changes in condition, assessments, and interventions is completed weekly, or as often as needed, and that the progress is documented in the chart notes.  

2. Resident 4's 01/01/23 through 01/30/23 MAR was reviewed and identified the following:

* Resident 4 was prescribed PRN Acetaminophen (for pain) and PRN Morphine (for pain). The MAR lacked parameters instructing staff on which pain medication to use first or under  what conditions;

* Bowel medications included PRN Bisacodyl, PRN Docusate and PRN Senokot for constipation and lacked parameters instructing staff on the order in which to administer the PRNs and under what circumstances; and  

* PRN Sinemet (for Parkinson's) was ordered to be given three times a day as needed for tremors. The MAR lacked clear instructions for unlicensed staff related to how far apart to administer the doses.

The need to ensure the MAR had clear parameters and instructions for staff as required for PRN medications and when more than one PRN medication was prescribed for the same condition was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 01/31/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, had resident-specific parameters for PRN medications and clear instructions to staff for 2 of 2 sampled residents (#s 3 and 4) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 3's 01/01/23 through 01/30/23 MAR was reviewed and identified the following:

* Resident 3 was prescribed PRN Tylenol (for pain) and PRN Oxycodone (for pain). The MAR lacked parameters instructing staff on which pain medication to use first; and

* PRN Oxycodone, BID, lacked clear instructions for unlicensed staff regarding the length of time before the medication could be given again.

The need to ensure the MAR had clear parameters and instructions for staff when more than one PRN medication was prescribed for the same condition was reviewed with Staff 1 (Administrator) on 02/01/23. She acknowledged the findings.

1) Resident MARs will be reviewed to ensure parameters are in place for PRN medication, instructing staff on which order to use medications when multiple medications are available for the same reason.

2) Additional training will be given to staff regarding the importance of having specific details from the prescriber when a PRN medication order is received for a diagnosis that has multiple medications for the same symtoms.  Any incomplete orders will be referred back to the prescriber for clarification.

3) Resident MARs will be reviewed quarterly by Administrator or RCC to ensure detailed and correct parameters are in place.

4) Adminstrator and RN will be responsible to ensure parameters are in place.   

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters did not exceed 120 degrees Fahrenheit (F) when installed in locations which were subject to incidental contact by individuals. Findings include, but are not limited to:

During a tour of the building with Staff 4 (Maintenance Manager) on 01/31/23, wall-mounted cadet heaters were observed in two common area corridors on the first floor. The heaters were located where residents could come into incidental contact with them. The heaters were on and the metal surfaces, measured with the surveyor's digital thermometer, were found to exceed 120 degrees Fahrenheit.

The heaters were discussed with Staff 4, and the thermostat knobs were removed to prevent increasing the temperature of the heaters until a long-term plan could be determined by the facility.

The need to ensure heating surfaces did not exceed 120 degrees Fahrenheit when located in areas where incidental contact could occur was discussed with Staff 1 (Administrator) and Staff 4 on 01/31/23. They acknowledged the findings.

1) Immediate action was taken by removing knobs from the hallway heaters. Covers were ordered as recommended by the surveyors and installed 2 days later.

2) Covers are attached to the wall by screws and will remain in place at all times. The building manager will ensure all heater surfaces will not exceed 120 degrees Fahrenheit.

3) The building manager or designee will check all heaters and covers monthly to ensure that they are in good repair and within recommended heat ranges.

4) The administrator will check in with the building manager monthly to make sure the heaters are being checked.