CARING FOR LOVED ONES

Based on documentation review, record review, and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery.

Findings include:

1. A review of facility documentation revealed an undated policy and procedure titled "Fall Prevention." However, the policy did not include the initial training and continued competency training requirement.

2. A review of E3's and E4's personnel records revealed no documentation of initial training or continued competency training in fall recovery.

3. A review of E5's personnel record revealed no documentation of initial training or continued competency training in fall prevention and fall recovery.

4. In an interview, E2 acknowledged the facility did not develop and administer a training program for all staff regarding fall prevention and fall recovery.

Based on documentation review, observation, record review, and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of compliance with the requirements in Arizona Revised Statutes (A.R.S.) \'a7 36-411(C), for one of five personnel records sampled.

Findings include:

1. A.R.S. \'a7 36-411(C) states: "C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency..."

2. The Compliance Officer observed E5 working at the facility for the duration of the time the Compliance Officer was on site.

3. A review of facility policies and procedures revealed a policy titled "Fingerprinting Requirements" which stated, "All personnel including managers, caregivers, assistant caregivers, volunteers who provide direct care to the residents shall have documentation with compliance with fingerprint requirements...The manager shall keep a documentation of the fingerprint clearance card and, good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in an assisted living facility."

4. A review of E5's personnel record revealed E5 was hired as an assistant caregiver. E5's personnel record revealed no documented good faith efforts to contact previous employers to obtain information or recommendations relevant to E5's fitness to work in a residential care institution.

5. In a joint interview, E2 and E3 acknowledged the personnel record for E5 did not include documentation of compliance with the requirements in A.R.S. \'a7 36-411(C).

Based on documentation review, record review, and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the assisted living facility, and, if the individual was requesting or expected to receive supervisory care services, personal care services, or directed care services, was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for one of two residents sampled.

Findings include:

1. A review of the facilities policies and procedures revealed a document titled, "Resident Agreement," which stated, "...The manager or manager's designee shall ensure that before or at the time of acceptance of an individual, the individual submits documentation that is dated within 90 calendar days before the individual is accepted and: Identifies if an individual is requesting to receive supervisory care services, personal care services, or directed care services: Includes whether the individual requires continuous medical services, continuous or intermittent nursing services, or restraints, and is dated and signed by a Physician, Registered Nurse Practitioner, Registered Nurse, or Physician Assistant..."

2. A review of R1's medical record revealed a document titled, "Determination form to identify if resident is appropriate for assisted living services based upon the facility's scope of services," which stated R1 was to receive directed care services. The document was signed by a registered nurse, but was not dated.

3. In an interview, E2 acknowledged R1's pre-admission determination documentation was signed, but not dated by a registered nurse.

Based on record review, observation, and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for one of two residents sampled.

Findings include:

1. A review of R1's medical record revealed a medication order dated January 28, 2023 for "Temazepam 15 mg (milligrams) Capsule, 1 Cap, Oral, take 1 cap by mouth daily at bedtime".

2. Further review of R1's medical record revealed a Medication Administration Record (MAR) dated May 2023. However, there was no documentation indicating R1 received "Temazepam" as ordered in May 2023.

3. The Compliance Officer observed a bottle of "Temazepam 15 MG capsules" included with R1's medications. The label on the medication bottle stated, "Take 1 capsule by mouth every night at bedtime scheduled for insomnia."

4. In an interview, E2 reported E1 administered the "Temazepam" to R1 as ordered on every evening in May 2023. E2 acknowledged the administration of R1's "Temazepam" was not documented in R1's medical record.