- Effective date
- 10/3/2018
- End date
- 3/1/2019
- Reference number
- CO18652
- Allegation
- Failed to provide safe environment
- Description
- Preliminary APS investigation report #BC180488, with an incident date of October 1, 2018 indicates the following: The facility failed to provide a safe environment and to ensure resident safety when a fire alarm was activated by a system failure. Due to mobility issues and the facility elevator being inoperable during the event, multiple residents called 911 requesting help to exit the building. The facility also failed to have an appropriate evacuation plan in place and ensure adequate staff were available to assist residents in an emergency. When the incident occurred, there were approximately sixtyfive residents in the building with one caregiver and one medication technician on staff. During the incident, it was reported Resident #1 had exited or fell from their thirdfloor window. Resident #1 was subsequently found on the ground outside the facility and transported to the hospital with life threatening injuries. In addition, DHS finds that the residents of the facility are at risk of immediate jeopardy. Terms include Restriction of Admissions (ROA); Staffing requirements 2 Direct Caregivers per floor on day and swing shift and 1 on night. 1 float on night shift and 1 Med Tech per shift; Building Requirements; Fire and Life Safety Drill requirements. Amending Order based on survey to include 1) continuing ROA; 2) RN consultant; 3) Staffing requirements; 4) Building requirements; 5) Doors; 6) Fire & Life Safety doumentation; 7) RN to attend "Role of the RN in CBC through Leading Age on December 46, 2018; and 8) All staff to complete Abuse reporting training through Oregon Care Partners. Second Amendment based on correspondence from a local EMT regarding being called to facility to assist a resident. Terms include ROA, RN consultant, staffing requirements, abuse reporting training, staff training on uses of oxygen and monitoring oxygen machines. Third Amendment based on consultant recommendation to allow 1 resident admission per 14 day period with prior consultant approval of each admission. Terms include limited admissions, RN consultant, staffing requirements, abuse reporting training, staff training on uses of oxygen and monitoring oxygen machines. On February 13, 2019, relicensure visit #1 (#N99R11) was completed by CBC survey team and facility was found to be back in substantial compliance. All terms of the Condition were met and the Department has withdrawn the Condition effective 2/28/19.
- Findings
- Transfer To Hospital For Treatment
- Sanction
- RCFCD18-012