BROOKDALE EAST MESA

Based on documentation review and interview, the manager of an assisted living center who contacted emergency responders on behalf of a resident failed to provide to the emergency responders a written document that included all information required in A.R.S. \'a7 36-420.04, for one of one applicable residents sampled. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident.

Findings include:

1. A review of facility documentation revealed an incident report dated July 31, 2024. The incident report revealed R1 exhibited aggressive behavior which resulted in the facility calling emergency medical services.

2. In an interview, the Compliance Officer requested a copy of the documentation provided to the emergency responders for R1. The Compliance Officer received a Face Sheet, a medication list, and a copy of R1's advance directives. However, the documentation did not include the following required information:
-The reason or reasons the emergency responder was requested on behalf of R1; and
-A copy of R1's health insurance portability and accountability act (HIPAA) release authorizing a receiving hospital to communicate with the assisted living center to plan for R1's discharge.

3. In an interview, E1 acknowledged the documentation provided to emergency medical services did not include all information required in A.R.S. \'a7 36-420.04.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of one resident reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication.

Findings include:

1. A review of R5's medical record revealed written service plans dated December 18, 2023 and March 18, 2024. The service plans indicated R5 received medication administration.

2. A review of R5's medical record revealed a signed medication order dated October 13, 2023 for "Nayzilam 5 milligrams (MG)/0.1 milliliter (ML) Solution as directed nasally as needed [PRN] seizure cluster 30 days."

3. A review of R5's medical record revealed a January 2024 medication administration record (MAR). The MAR stated, "Nayzilam Nasal Solution 5 MG/0.1 ML (Midazolam (Anticonvulsant)) spray in nostril as needed for short term treatment of seizure clusters give one spray in one nostril for seizure cluster." The MAR indicated R5 did not receive the medication in January 2024.

4. A review of Department documentation revealed R5 experienced a seizure on January 17, 2024.

5. In an interview, E2 confirmed R5 did experience a seizure on January 17, 2024. E2 reported R5 did not receive the Nayzilam as prescribed as the staff did not know there was an order for the medication to be administered as needed if R5 experienced a seizure.

6. In an interview, E2 acknowledged R5's medication was not administered in compliance with the medication order. E2 reported the facility has since conducted a training on seizure protocol and the use of PRN medications.

7. This is a repeat deficiency from the compliance and complaint inspection conducted September 27, 2023.

Based on record review and interview, the manager failed to ensure a resident had a written service plan that was developed with assistance and review from the resident's representative, for six of six residents sampled. The deficient practice posed a risk if the resident's representative was unable to participate in the development or review the service plan to provide essential information.

Findings include:

1. A review of R1's medical record contained a service plan dated August 24, 2023, for directed care services. The service plan revealed no signature of the resident's representative indicating the service plan was developed with assistance and reviewed by the resident's representative.

2. A review of R2's medical record contained a service plan dated August 30, 2023, for directed care services. The service plan revealed no signature of the resident's representative indicating the service plan was developed with assistance and reviewed by the resident's representative.

3. A review of R3's medical record contained a service plan dated August 31, 2023, for directed care services. The service plan revealed no signature of the resident's representative indicating the service plan was developed with assistance and reviewed by the resident's representative.

4. A review of R4's medical record contained a service plan dated August 30, 2023, for directed care services. The service plan revealed no signature of the resident's representative indicating the service plan was developed with assistance and reviewed by the resident's representative.

5. A review of R5's medical record contained a service plan dated August 22, 2023, for directed care services. The service plan revealed no signature of the resident's representative indicating the service plan was developed with assistance and reviewed by the resident's representative.

6. A review of R6's medical record contained a service plan dated September 25, 2023, for directed care services. The service plan revealed no signature of the resident's representative indicating the service plan was developed with assistance and reviewed by the resident's representative.

7. In an interview, E1 and E2 acknowledged the service plans for R1, R2, R3, R4, R5, and R6 were not signed to indicate the service plans were developed with assistance of the resident's representative.

Based on interview and record review, the manager failed to ensure that for one of one sampled residents, who were unable to ambulate even with assistance, the resident's primary care provider or other medical practitioner examined the resident at least once every six months throughout the duration of the resident's condition, to determine if the resident's needs could be met based upon a current examination and the assisted living facility's scope of services. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. In an interview, E2 reported R6 was non-ambulatory and received directed care services.

2. A review of R6's (accepted in 2021) medical record revealed a service plan dated September 25, 2023. The service plan stated R6 "requires a two-person assist for transferring during:
-All transfers
-Dressing or Grooming
-Showering or Bathing
-Bathroom Assistance."

3. A review of R6's medical record revealed documentation to include whether the resident's primary care provider or other medical practitioner examined the resident, and signed and dated a determination stating the resident's needs could be met by the assisted living facility dated within 30 days of acceptance to the facility. However, current documentation to include whether the resident's primary care provider or other medical practitioner examined the resident at least every six months, and signed and dated a determination stating the resident's needs could be met by the assisted living facility was not available for review.

4. In an interview, E1 acknowledged current documentation to include whether R6's primary care provider or other medical practitioner examined the resident at least every six months, and signed and dated a determination stating the resident's needs could be met by the assisted living facility was not available for review.

Based on record review and interview, the manager failed to ensure the service plan for a resident included the determination in R9-10-814(B)(2)(b)(iii), for one of five residents sampled who received directed care services. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

R9-10-814(B)(2)(b)(iii): A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if...2. The following requirements are met at the onset of the condition or when the resident is accepted by the assisted living facility:...b. The resident's primary care provider or other medical practitioner:...iii. Signs and dates a determination stating that the resident's needs can be met by the assisted living facility within the assisted living facility's scope of services and, for retention of a resident, are being met by the assisted living facility...

1. In an interview, E2 reported R6 was non-ambulatory.

2. A review of R6's medical record revealed a document titled, "Personal Service Plan" dated September 25, 2023. The document stated, R6 "requires a two-person assist for transferring during:
-All transfers
-Dressing or Grooming
-Showering or Bathing
-Bathroom Assistance."

3. Further review of R6's medical record revealed admission orders dated September 10, 2021. However, the medical record did not include the determination in R9-10-814(B)(2)(b)(iii).

4. In an interview, E1 acknowledged R6's service plan did not include the determination in R9-10-814(B)(2)(b)(iii) as required.

Based on observation and interview, the manager failed to ensure that a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available in a bedroom being used by a resident receiving directed care services. The deficient practice posed a risk to the health and safety of residents if unable to summon for help in an emergency.

Findings include:

1. During a facility tour, the Compliance Officer observed in some resident rooms, there were no call bells, intercoms, or other mechanical means available for the resident to alert employees of the residents' needs or emergencies.

2. In an interview, E1 acknowledged some resident rooms were not equipped with a working bell or other mechanical means available to the resident to alert employees of the residents' needs. E1 reported the resident was given a means to alert employees only if requested by the resident's family.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for one of six residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication.

Findings include:

1. A review of R5's medical record revealed R5 received medication administration. The medical record revealed a signed medication list dated January 27, 2022. The medication list included Metoprolol Succinate 25 milligrams (mg), 1 tablet once a day, with an additional comment to hold the medication if R5's systolic blood pressure measured below 120 and/or heart rate measured below 60.

2. A review of R5's medical record revealed a medication administration record (MAR) for September 2023. The MAR indicated Metoprolol 25 mg was administered on September 2, 2023, September 14, 2023, and September 22, 2023. However, the medication should not have been administered as R5's systolic blood pressure measured 111, 103, and 109, respectively.

3. In an interview, E1 and E2 acknowledged the Metoprolol was not administered in compliance with a medication order. E1 and E2 acknowledged it is unknown whether R5 did or did not receive the medication.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months; and included all individuals on the premises except for a resident whose medical record contains documentation that evacuation from the assisted living facility would cause harm to the resident. The deficient practice posed a risk if employees were unable to implement a disaster plan.

Findings include:

1. A review of facility documentation revealed no evacuation drills had been conducted.

2. In an interview, E1 acknowledged the employee and resident evacuation drills were not conducted and documented at least once every six months.