GOLDEN CARE

Based on documentation review, record review, and interview, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery that included continued competency training. The deficient practice posed a risk to the physical health and safety of a resident.

Findings include:

1. Review of facility documentation revealed a document titled "Staff Training Program and Procedure (Fall Prevention and Fall Recovery)" that stated "...3. Orientation and review will be held annually during the review and assessment of Annual Quality Management to discuss all scenarios and outcome of past incident. 4. The Training and Orientation form will be updated to document the date of Fall Prevention and Fall Recovery training and review program."

2. Review of E1's personnel record revealed E1 worked as a manager and had a hire date of September 1, 2022. The personnel record revealed documentation of fall prevention and fall recovery training dated December 21, 2022. However, current documentation was not available indicating E1 completed fall prevention and fall recovery training.

3. In an interview, E1 acknowledged documentation was not available that showed E1 completed current training for fall prevention and fall recovery.

Based on documentation review, record review, and interview, the manager failed to ensure a resident medical record contained documentation of notification of the resident of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. \'a7 36-406(1)(d), to one of one resident reviewed. The deficient practice posed a potential illness risk to residents.

Findings include:

1. A.R.S. \'a7 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director."

2. Review of R2's medical record revealed R2 received the flu vaccination February 22, 2022. However, current documentation was not available that showed the flu vaccination was offered or received. Additionally, R2's medical record revealed R2 refused the pneumonia vaccination October 19, 2021. However, current documentation was not available that showed the pneumonia vaccination was offered or received. Based on R2's acceptance date, this documentation was required.

3. In an interview, E1 acknowledged R2's medical record did not include current documentation that showed the flu and pneumonia vaccinations were offered or received.

Based on record review and interview, the manager failed to ensure the facility did not retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner, every six months, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one of two residents reviewed who were confined to a bed or chair. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. Review of R2's medical record revealed a current written service plan dated August 25, 2023. This service plan stated "Non Ambulatory" and "Bed bound".

2. Review of R2's medical record revealed a written determination from R2's medical practitioner signed and dated December 9, 2019. However, documentation was not available that stated R2's needs could be met by the facility and R2's needs were within the facility's scope of services, at least once every six months.

3. In an interview, E1 reported R2 was unable to ambulate even with assistance since acceptance and acknowledged R2's medical practitioner did not provide a written determination every six months.

Based on record review and interview, the manager failed to ensure a resident received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility, for one of two residents reviewed. The deficient practice posed a health and safety risk if the resident needed to exit the facility in an emergency.

Findings include:

1. Review of R2's medical record revealed an evacuation plan orientation form dated December 4, 2019. However, this evacuation plan orientation was from R2's previous facility. Documentation of orientation to the exits from the current assisted living facility and the route to be used when evacuating the current assisted living facility was not available for review. Based on R2's date of acceptance, this documentation was required.

2. In an interview, E1 reported the evacuation plan orientation reviewed in R2's record was from a previous facility. E1 acknowledged documentation was not available that showed R2 was oriented to the current facility's evacuation plan within 24 hours of acceptance.

Based on observation and interview, the manager failed to ensure a rechargeable fire extinguisher was serviced at least once every 12 months. The deficient practice posed a health and safety risk to the residents if a fire extinguisher was needed and did not work properly.

Findings include:

1. During the facility tour with E1, the Compliance Officer observed a rechargeable fire extinguisher. This fire extinguisher had a service tag attached dated March 2022.

2. In an interview, E1 acknowledged the rechargeable fire extinguisher was not serviced at least once every 12 months.

Based on documentation review, record review, and interview, the health care institution failed to implement tuberculosis (TB) infection control activities as specified in R9-10-113. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance and posed a TB exposure risk to residents and staff.

Findings include:

1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)...c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution; d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis..."

2. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used."

3. Review of R1's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R1 had signs or symptoms of TB. Based on R1's acceptance date, this documentation was required.

4. Review of E2's personnel record revealed E2 worked as a caregiver and had a hire date of December 10, 2021. The personnel record revealed documentation of TB training dated December 27, 2022. However, current training and education related to recognizing the signs and symptoms of TB was not available.

5. Review of E3's personnel record revealed E3 worked as a caregiver and had a hire date of June 5, 2023. Review of E3's personnel record revealed a negative TB skin test that was less than 12 months old, however no additional documentation of freedom from infectious TB was available for review. Based on E3's hire date, this documentation was required.

6. Review of E4's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if E4 had signs or symptoms of TB. Additionally, E4's personnel record revealed a negative TB skin test that was less than 12 months old, however no additional documentation of freedom from infectious TB was available for review. Based on E4's hire date, this documentation was required.

7. Review of facility documentation revealed no documentation of an annual assessment of the health care institution's risk of exposure to infectious TB.

8. In an interview, E1 acknowledged the facility had not implemented a TB infection control program as specified in R9-10-113.