Print Inspection: YT49

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 9/28/2022.  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 medications as prescribed. Findings include:

On 9/28/2022 Compliance Specialist (CS) reviewed Resident #1 (R1) and Resident #2 (R2) medication administration records (MARs) and progress notes for September 2022 as well as the facilities policy and procedures for medication errors. CS identified that on 9/14/2022 R1 missed a dose of medication X. A same day incident report was made. On 9/15/2022 R2 ' s nighttime medication X, Y and Z was found left in medication cart when morning medication was being prepared resulting in R2 not receiving their medications, and the medication technician having signed off as having administered medication. On 9/16/2022 an Incident report and proper notifications were made. Both medication errors were followed by alert charting of both R1 and R2.

During separate interviews on 9/28/2022 Staff #1 (S1) and Staff #2 (S2) were aware of the medication error. The facility proceeded to investigate, notify physicians, individual service plan, and notified local adult protective services. Both S1 and S2 stated all staff completed in service training after medication errors for understanding of narcotic counts, medication error prevention, diabetic education, and abuse and neglect training.

Verbal Plan of Correction:

The facility documented the incident, filled out a med error report and followed up per their policy and procedure. Training was provided to all med techs.