Fairlawn Health and Rehab of Cascadia

Based on observation and interview it was determined the facility failed to ensure a homelike environment for 1 of 2 resident rooms (Room #29) reviewed for environment. This placed residents at risk for a lessened quality of life. Findings include:

An observation on 12/2/24 at 9:56 AM revealed the cloth recliner chair in Room 29 was stained with an unknown brown dried residue on the seat of the chair and on the arm rests.

On 12/4/24 at 2:14 PM Staff 10 (CNA) stated the chair in Room 29 was "filthy" and did not have a cleanable surface.

On 12/4/24 at 2:23 PM Staff 3 (Infection Preventionist) stated the chair was "very dirty" and did not have a cleanable surface.

On 12/6/24 at 12:54 PM Staff 12 (Housekeeping) stated she had a monthly cleaning schedule for resident recliners but did not clean the one in Room 29 because it was cloth.

On 12/6/24 at 2:20 PM Staff 1 (Administrator) confirmed the chair was dirty and had a bad odor.

Based on interview and record review it was determined the facility failed to ensure a safe discharge for 1 of 2 sampled residents (#210) reviewed for safe discharges. This placed residents at risk for unmet care needs. Findings include:

Resident 210 was admitted to the facility in 7/2024 with diagnoses including periprosthetic fracture around other internal prosthetic joint (a bone fracture that occurs near or around a joint replacement implant).

Resident 210's 7/31/24 St. Louis University Mental Status Examination (SLUMS) score indicated the resident experienced dementia.

Resident 210's 9/5/24 Discharge MDS Assessment revealed the resident was cognitively intact, had an indwelling catheter, was occasionally incontinent of urine, required setup or clean-up assistance with showering and to put on or take off foot wear and required supervision or touch assistance with car transfers and to go up or down a curb or one step.

Resident 210's 9/5/24 Physician Orders directed the resident to receive hydralazine (a medication used to treat high blood pressure) three times daily. The medication was to be held for a systolic (the highest pressure in your arteries when your heart beats) blood pressure less than 110.

A review of Resident 210's 9/2024 Progress Notes revealed the following:
-A 9/2/24 Progress Note revealed Resident 210 continued to experience episodes of dizziness, unstable blood pressures and urine retention.
-A 9/3/24 Physician Order directed the resident to be straight catheterized (a procedure that involves inserting a straight catheter into the urethra to drain the bladder) if her/his post void residual (PVR, the amount of urine left in the bladder after urinating) was more than 300 ml every six hours. If the resident continued to have greater than 300 ml PVR, the resident was to be straight catheterized again. If she/he was straight catheterized three times, a foley catheter (a medical device that helps drain urine from the bladder) was to be inserted. If she/he refused the foley catheter, the resident was to be sent to the emergency department.
-A 9/3/24 Skilled Charting Note revealed the resident was concerned about her/his ongoing urine retention and decided the safest thing would be to discharge home with a foley catheter.
-A 9/3/24 Social Service Note indicated Resident 210 wanted to discharge on 9/5/24.
-A 9/5/24 Social Service Note written at 1:28 PM indicated Witness 2 (Family Member) was called per Resident 20's request to notify Witness 2 of her/his discharge.
-A 9/5/24 Health Status Note written at 4:15 PM indicated Resident 210 had a foley catheter re-inserted STAT (immediately) prior to her/his discharge from the facility.

Resident 210's 9/5/24 Utilization Review Physical Therapy Progress Section revealed the resident lived with family in a one story home with three steps to enter. The resident required a front wheel walker and supervision with transfers. The Discharge Plan Section indicated the discharge plan was for the resident to go home with Witness 2 and with home health but home health had not been ordered.

Resident 210's 9/5/24 Planned Discharge Summary revealed the resident discharged from the facility on 9/5/24 at 2:00 PM, went home as planned and was accompanied home by the driver of a transportation company, needed assistance with lower extremity dressing, personal hygiene and with stairs and was moderately independent for making decisions. In the section of the summary entitled "Resident Education Materials Provided," there was no check in the boxes for catheter care or monitor blood pressure.

Resident 210's 9/5/24 Physician Discharge Summary indicated the resident discharged home with family on 9/5/24 at 2:06 PM.

No evidence was found in Resident 210's clinical record to indicate she/he was could independently administer her/his medications or provide her/his own catheter care, the resident was safe to be alone when she/he experienced on-going episodes of dizziness, the resident's family was notified of her/his discharge from the facility prior to her/his day of discharge, confirmation a family member would be at the resident's house to assist the resident with the stairs or care as needed on the day she/he discharged from the facility or that a family member had received instructions on the resident's medications or catheter care.

On 12/5/24 at 11:04 AM Resident 210 stated she/he informed the facility she/he intended to discharge from the facility on 9/5/24 "weeks in advance" of her/his discharge. Resident 210 stated on her/his day of discharge, "everyone was running around to get paperwork done at the last minute." Resident 210 stated she/he did not recall reviewing her/his medication list at the time of discharge or care for her/his catheter.

On 12/5/24 at 12:15 PM Witness 2 stated Resident 210's discharge from the facility was "really confusing and sad" and there was "no communication regarding a plan to discharge." Witness 2 stated she was initially informed of Resident 210's discharge from the facility on 9/5/24, just two hours prior to when Resident 210 was anticipated to arrive home. Witness 2 stated when she was informed of the discharge, she told the facility she was out of town and did not know if she would be home at the time Resident 210 arrived. Witness 2 stated she was informed at this time that the resident would be returning home with a foley catheter in place and she had not been trained on the care of a foley catheter. Witness 2 stated she was not informed of what medications the resident was discharged with prior to her/his discharge or if she/he had the necessary supplies for her/his catheter. Witness 2 stated the medication card that contained the resident's blood pressure medication did not match the orders the facility sent home with the resident, and when Resident 210's blood pressure dropped, she/he "was not cognitively with it." Witness 2 further stated home health was not set up at the time of Resident 210's discharge, and it was the facility's responsibility to make sure "we had the resources available" when the resident returned home since we live in a small community where access to resources was limited and home health services were over an hour away.

On 12/5/24 at 1:48 PM Staff 13 (CNA) stated Resident 210 "was confused and forgetful mostly daily." Staff 13 stated Resident 210 could not independently complete her/his own catheter care at the time of her/his discharge.

On 12/6/24 at 11:26 AM Staff 15 (RNCM) stated family was to be notified of a discharge "three days ahead of time and throughout the stay." Staff 15 stated residents with a foley catheter required education on catheter care and "nurses should document resident abilities in the progress notes." Staff 15 stated residents with medication parameters, such as holding a medication dependent on a blood pressure reading, would need to be trained to take their blood pressure. Staff 15 stated if a resident was determined to discharge home with family, a family member would have "to be present when going through all of the patient's medications" and she "would expect a family member present for catheter care instructions as well." Staff 15 stated Resident 210 had a foley catheter placed the day she/he discharged from the facility because the resident "could not straight catheterize on [her/his] own." Staff 15 stated Resident 210 experienced "intermittent dizziness," the resident's blood pressure was "kind of elevated" and staff worked with the resident's provider to change her/his cardiac medication to see what would work. Staff 15 stated the plan was for Resident 210 to discharge home with Witness 2 as the resident required assistance with her/his catheter, needed assistance with transfers "for safety reasons" and was unable to care for her/himself when dizzy. Staff 15 stated Resident 210's foley catheter was placed at the "last minute" and the family "would have needed some kind of training." Staff 15 reviewed Resident 210's clinical record and confirmed there was no documentation to indicate the family was informed of her/his discharge from the facility prior to her/his date of discharge or that the family was provided any education regarding care of the resident's catheter or medication administration.

On 12/6/24 at 12:08 PM Staff 5 (Social Services) stated she was aware of Resident 210's plan to discharge "a couple of days" prior to her/his actual discharge from the facility on 9/5/24. Staff 5 stated she "thought" she tried to call Witness 2 to inform her of the resident's discharge on 9/4/24 but she did not connect with Witness 2 or leave her a voicemail. Staff 5 stated she spoke with Witness 2 on 9/5/24 about the resident's discharge and was told Witness 2 may not be home when the resident arrived.

On 12/6/24 at 1:26 PM Staff 16 (Physical Therapy Assistant) stated Resident 210 "lived with family way far away." Staff 16 stated Resident 210 needed "supervision to do the steps at home and needed someone to always be with [her/him] at home."

On 12/6/24 at 2:22 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the findings and Staff 2 stated more training and documentation was needed.

Based on observation, interview and record review it was determined the facility failed to ensure safety interventions for fall prevention were followed for 1 of 4 residents (#26) reviewed for accidents. This placed residents at risk for accidents. Findings include:

Resident 26 was admitted to the facility on 11/8/23 with diagnoses including age-related osteoporosis with a current pathological fracture of her/his left femur (a chronic disease that causes bones to become brittle and porous, and a broken upper-leg bone) and severe vascular dementia with agitation (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain).

A review of Resident 26's 9/30/24 Quarterly MDS Assessment revealed she/he had severe cognitive impairment.

Resident 26's 9/30/24 Quarterly Fall Risk Assessment indicated she/he was at risk for falls related to her/his incontinence, impaired cognition and impaired functional mobility.

A review of Resident 26's care plan revealed she/he had a low bed and it was to be against the wall and in the lowest position with a fall mat at her/his bedside to minimize her/his risk of injuries from falls.

On 12/3/24 at 10:01 AM Resident 26 was observed to be in bed with a fall mat at her/his bedside. Her/his bed was elevated to a level for transfers and was not in the low position. There were no caregivers in her/his room.

On 12/5/24 at 9:24 AM Resident 26 was observed to be in bed, awake and watching television with the head of the bed elevated to approximately 30 degrees. There was a fall mat on the floor beside the bed and the bed was elevated to a height appropriate for wheelchair transfers. The bed was not in the low position and there were no caregivers in the room.

On 12/5/24 9:59 AM Staff 13 (CNA) stated Resident 26 was part of the facility's "Falling Star" program which indicated staff were to look inside Resident 26's room whenever they passed it to make sure she/he had not fallen, there was a fall mat at her/his bedside and her/his bed was in the lowest position. Staff 13 confirmed Resident 26 was in her/his bed and the bed was in wheelchair transfer height. Staff 13 stated Resident 26's bed should be in the lowest position when she/he was in it.

On 12/5/24 at 11:23 AM Staff 15 (RN) stated Resident 26 was assessed to be at risk for falls and had a history of falls. She stated she expected CNAs to follow Resident 26's care plan for her/his safety.

On 12/6/24 at 10:28 AM Staff 3 (LPN / Infection Preventionist) stated Resident 26 often sat in bed with her/his legs "dangling over the edge" and "it made us nervous." He added this was one of the reasons for Resident 26's fall prevention interventions.

On 12/06/24 at 2:23 PM Staff 1 (Administrator) stated she expected staff to follow care planned interventions because Resident 26 was at risk for falls.

Based on observation, interview and record review it was determined the facility failed to follow catheter care orders for 1 of 1 resident (# 53) reviewed for catheter care. This placed residents at risk for unmet care needs. Findings include:

Resident 53 was initially admitted to the facility in 10/2024 with diagnoses including urine retention (difficulty urinating) with the use of a Foley catheter to remove urine from the bladder.

A 10/3/24 BIMS indicated Resident 53 had normal cognitive function.

A 12/3/24 Neurosurgery Postoperative Visit note included instructions for Resident 53's Foley catheter to be changed after she/he returned to the nursing facility.

A 12/3/24 physician order stated the following: "Change Foley ASAP, was not changed during hospitalization."

On 12/4/24 at 9:53 AM Resident 53 stated she/he returned to the facility after a surgical procedure at the hospital and had orders to have her/his catheter changed immediately. Resident 53 stated her/his Foley catheter was not changed on 12/3/24.

On 12/5/24 at 9:50 AM Resident stated her/his Foley catheter was not changed on 12/4/24.

Review of the 12/2024 TAR on 12/5/24 revealed Resident 53's Foley catheter change was not completed on 12/3 or 12/4.

On 12/5/24 at 10:28 AM Staff 20 (RCM/LPN) stated Resident 53's catheter should have been changed as soon as possible and confirmed that change was not performed as ordered on 12/3/24 or 12/4/24.

On 12/5/24 at 11:13 AM Staff 18 (RN) stated she provided care to Resident 53 on 12/3/24 and confirmed she did not change Resident 53's Foley catheter. Staff 18 stated she intended to contact Resident 53's physician for clarification of catheter change orders, but did not contact the physician.

On 12/5/24 at 12:03 PM Staff 19 (LPN) stated she provided care to Resident 53 on 12/4/24 and confirmed the Foley catheter change was not completed because she ran out of time.

On 12/5/24 at 11:37 AM Staff 2 (DNS) confirmed Resident 53's catheter was not changed as ordered.

Based on observation, interview and record review it was determined the facility failed to ensure food and beverages were labeled and stored in a manner to minimize spoilage and cross contamination for 1 of 1 kitchen reviewed for sanitary conditions. This placed residents at risk for foodborne illness. Findings include:

1. The facility's 4/2018 Food Storage: Cold Foods Policy Statement specified, "All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination."

The facility's 9/2017 Food Storage: Dry Goods Policy Statement specified, "All packaged and canned food items will be kept clean, dry, and properly sealed."

On 12/2/24 at 9:43 AM during the initial tour of the facility's kitchen, the following was observed:
-Three trays of unlabeled and undated cups of milk and juice on the top shelves of the middle and right refrigerators in the food preparation area;
-An uncovered and unlabeled large plastic bin of dry oat cereal sitting on the top shelf of a wheeled cart in the dry storage room;
-An opened and undated five-pound plastic tub of peanut butter with peanut butter smeared on the top and edge of the lid and on the sides of the tub on the top shelf of a wheeled cart in the dry storage room. The tub was slick and unclean;
-An opened and undated bag of salad greens on the top shelf of the refrigerator in the dry storage room; and
-A plastic bin containing four eggs, one with a broken shell, on the bottom shelf of the refrigerator in the dry storage room.

On 12/2/24 at 9:55 AM Staff 14 (Dietary Manager) stated the lettuce shouldn't be left open as it was observed. She added, "It needs to be closed up and wrapped with plastic and labeled with a date." She acknowledged the cracked shell and stated she expected staff to throw out any eggs with broken shells. She added, "The peanut butter is definitely not clean like that. It should be wiped down during the process if it gets messy." Staff 14 also stated the bin of oat cereal should was not be uncovered in dry storage storage. She expected the bin to be emptied and taken to the dishwashing station rather than left uncovered in the dry storage room.

2. The facility's 9/2017 Equipment Policy Statement specified, "All non-food contact equipment will be clean and free of debris

On 12/2/24 at 10:06 AM the gaskets on the interiors of the refrigerator doors were observed to be grimey with solid and liquid food debris collected in the plastic flanges. The gaskets were observed to be pulling away from doors which created an incomplete seal. Staff 14 (Dietary Manager) stated she cleaned the gaskets regularly but they got dirty again "because they are old and they don't close well. Stuff drops from above." Staff 14 stated she expected her staff to keep it clean because "It shouldn't be like this." Staff 14 stated the facility needed a new refridgerator.

3. On 12/2/24 at 10:07 AM the kitchen was observed to have multiple dirty in-floor drains. The drain opposite the food preparation and steam table area had black grime caked around the inset grate.

The drain adjacent to the ice machine was also observed to be caked with so much black grime it was not possible to see the inset grate. Additionally, food debris and other kitchen waste was observed on the floor adjacent to the drain next to the ice machine.

Staff 14 (Dietary Manager) confirmed these observations and stated the drains were dirty and needed to be cleaned.

On 12/6/24 at 2:14 PM Staff 1 (Administrator) acknowledged these findings and stated she expected the kitchen staff to keep the kitchen clean and sanitary and items should be covered, labeled and dated to prevent spoilage and cross-contamination.

********************
OAR 411-087-0100 Physical Environment: Generally

Refer to F584
********************
OAR 411-086-0060 Comprehensive Assessment and Care Plan

Refer to F660
********************
OAR 411-086-0140 Problem Resolution and Preventive Care

Refer to F689 and F690
********************
OAR 411-086-0250 Dietary Services

Refer to F812
********************

Based on interview and record review it was determined the facility failed to complete a discharge summary for 1 of 3 sampled residents (#1) reviewed for discharge. This placed residents at risk for unmet discharge needs. Findings include:

Resident 1 admitted to the facility on 8/2023 with diagnoses including malnutrition.

Resident 1's care plan, revised 9/29/23, revealed she/he planned to discharge home and the facility would make referrals for home health, physical and occupational therapy, and other medically related services.

On 11/18/24 at 11:05 AM, Staff 4 (Social Services Director) stated she was responsible for resident discharges. She stated she made community referrals including home health, faxed physician orders to community providers and completed discharge summaries as part of the discharge process. She confirmed Resident 1 did not have a discharge summary in her/his clinical record in 2023.

On 11/19/24 at 10:16 AM, Witness 1 (Home Health Staff) stated she attended a care conference a couple of days before Resident 1 discharged last year. The facility agreed they would make referrals for home health and send the necessary paperwork to the home health agency. Witness 1 stated she made multiple phone calls to Staff 3 (Previous SSD) requesting physician orders and instructions but did not receive a return call from anyone at the facility.

Resident 1's clinical record was reviewed and did not include a discharge summary. Progress notes revealed she/he discharged home on 9/17/23.

Staff 3 was no longer working at the facility and unable to be interviewed.

On 11/21/24 at 3:30 PM, Staff 1 (Administrator) was informed of the investigative findings and provided no additional information.

Based on interview and record review it was determined the facility failed to follow physician orders for 2 of 3 sampled residents (#s 3 and 4) reviewed for bowel care. This placed other residents at risk for bowel complications. Findings include:

On 3/31/24, the Past Noncompliance was corrected when the facility implemented an updated bowel protocol, which included:

-Bowel protocol binders are located at each nursing station;
-New bowel forms were created for every resident and reviewed daily;
-Residents with no documented bowel movement after 72 hours were added to the list, monitored and followed up by nursing staff;
-Staff in-serviced on the facility's bowel protocol.
-Interviews conducted with nursing staff and confirmed bowel protocol was in place.

1. Resident 3 admitted to the facility in 9/2023, with diagnoses including atrial fibrillation and constipation.

Resident 3's physician orders dated 9/28/23 indicated she/he was to be administered bowel medications daily. The bowel protocol on the resident's orders and 10/2023 MAR indicated the following steps were to be taken:

-Step 1-Administer 17 grams of Polyethylene Glycol Powder every 48 hours for no bowel movement in two days.
-Step 2-Administer Bisacodyl suppository every 72 hours for no bowel movement in three days. If resident refused the suppository, administer two Bisacodyl tablets every 72 hours.
-Step 3-Administer a Fleet Mineral Oil enema for no bowel movement in four days.
-Step 4-Administer Lactulose Solution, 30 ml every 8 hours as needed if unrelieved by bowel protocols.

Resident 3's bowel logs for 10/2023 revealed no bowel movement from 10/22/23 through 10/31/23.

Resident 3's 10/2023 MAR revealed she/he was given the following bowel medications and results:

-10/25/23 (three days after no bowel movement): Polyethylene Glycol Powder: Results - ineffective
-10/25/23: Bisacodyl tablets (3 days after no bowel movement): Results - ineffective
-10/30/23: Bisacodyl Suppository (8 days after no bowel movement): Results - ineffective
-10/31/23: Fleet Mineral Oil enema (9 days after no bowel movement): Results - ineffective
-10/31/23: Lactulose Solution (9 days after no bowel movement): Results - unknown

A nursing note dated 11/1/23 stated "CMA informed LN that patient is going on day 11 of no BM. Enema was given yesterday with no results. LN performed bowel assessment, abdomen soft and round, bowel tones in all four quadrants. Denies nausea or vomiting, denies any pain, eating and drinking well. Provider aware of lack of bowel movement, per verbal from provider scheduled 30 ml of Lactulose q 8 hrs until BM. Orders updated."

Resident 3's 11/2023 bowel log revealed she/he had a large bowel movement on 11/3/23.

Resident 3 was not interviewed due to discharging from the facility.

On 11/21/24 at 1:08 PM, Staff 2 (DNS) confirmed the resident's bowel protocol was not followed.

2. Resident 4 admitted to the facility in 10/2023 with diagnoses including stroke.

Resident 4's physician orders dated 10/20/23 indicated she/he was to be administered bowel medications daily. The bowel protocol on the resident's orders and her/his 10/2023 MAR indicated the following steps were to be taken:

-Step 1-Administer 17 grams of Polyethylene Glycol Powder every 48 hours for no bowel movement in two days.
-Step 2-Administer Bisacodyl suppository every 72 hours for no bowel movement in three days. If resident refused the suppository, administer two Bisacodyl tablets every 72 hours.
-Step 3-Administer a Fleet Mineral Oil enema for no bowel movement in four days.
-Step 4-Administer Lactulose Solution, 30 ml every 8 hours as needed if unrelieved by bowel protocols.

Resident 4's Nursing Admission Assessment dated 10/20/23 revealed no bowel movement since 10/18/23, when she/he was hospitalized.

Resident 4's bowel logs revealed no bowel movement from 10/20/23 through 10/23/23.

Resident 4's 10/2023 MAR revealed she/he was not given Polyethylene Glycol Powder from 10/20/23 through 10/23/23 and was not given a Bisacodyl suppository until 10/24/23, six days after her/his last bowel movement. The MAR indicated the suppository administered 10/24/23 was effective.

Resident 4 was no longer in the facility and was unable to be interviewed.

On 11/21/24 at 3:30 PM, Staff 1 (Administrator) and Staff 2 (DNS) were informed of the investigative findings and provided no additional information.

*************************************************

OAR 411-086-0160: Nursing Services - Discharge Summary

Refer to F661

*************************************************

OAR 411-086-0110: Nursing Services - Resident Care

Refer to F684

*************************************************

Based on interview and record review it was determined the facility failed to follow physician orders for medication administration for 1 of 3 residents (# 501) reviewed for medication administration timeliness. This placed residents at risk for reduced medication efficacy and adverse medication side effects. Findings include:

Resident 501 was admitted to the facility in 9/2023 with diagnoses including a urinary tract infection (UTI).

Physician Orders from 10/2023 included orders for the following medications to be administered at 7:15 AM:
- Polyethylene Glycol Power - Give 17 grams in the morning for bowel care.
- Potassium Chloride ER - Give half a tablet by mouth in the morning for supplement.
- Torsemide 100 mg - Give one tablet by mouth in the morning for heart health.
- Cipro 500 mg - Give one tablet by mouth twice a day for UTI for 10 days. (Started 10/10/23).
- Nitrofurantoin Macrocrystal 100 mg - Give one capsule by mouth in the morning for UTI prevention. (Started 10/20/23).

Review of a 10/2023 Medication Admin Audit Report revealed the following delays in medication administration:
- 10/5/23 - Administered at 9:48 AM
- 10/7/23 - Administered at 10:54 AM
- 10/13/23 - Administered at 9:18 AM
- 10/20/23 - Administered at 11:03 AM
- 10/21/23 - Administered at 10:11 AM
- 10/27/23 - Administered at 9:52 AM
- 10/28/23 - Administered at 8:51 AM

On 5/23/34 at 2:35 PM Staff 1 (Administrator) stated the administration for medications had a two hour window, which meant medications ordered to be administered at 7:15 AM could be administered between 6:15 AM and 8:15 AM. Staff 1 confirmed Resident 501 received her/his medications outside of this timeframe on the dates listed above.

Based on interview and record review it was determined the facility failed to administer Warfin (blood thinner) as ordered which resulted in a significant medication error for 1 of 3 sampled residents (#1) reviewed for medication administration. The placed the resident at risk for adverse side effects of medications. Findings include:

Resident 1 was admitted to the facility in 2023 with diagnoses including heart failure, chronic kidney failure, and atrial fibrillation.

Resident 1's Admission MDS identified Resident 1 with a BIMS score of 13 out of 15 which indicated no cognitive impairment.

Resident 1's signed Physician Order's revealed Resident 1 was ordered Warfin 2.5 mg by mouth every Monday, Friday, Saturday, and Sunday at bedtime to treat Resident 1's diagnosis of Atrial Fibrillation.

A 9/4/23 Incident Note revealed Staff 7 identified and documented that Resident 1 missed 3 doses of Warfin on Friday, 9/1/23, Saturday, 9/2/23 and Sunday 9/3/23.

The 9/2023 MAR revealed on Friday 9/1/23, Saturday 9/2/23, and Sunday 9/3/23, Resident 1 was not administered Warfin as prescribed by the provider.

On 10/16/23 at 12:47 PM Staff 7 (LPN) acknowledged Resident 1 missed 3 doses of her/his prescribed Warfin order and was required to receive a new medication order as a result.

On 10/18/23 at 10:30 AM Staff 1 (Administrator) and Staff 2 (DNS) confirmed findings and provided no additional information.

********************

OAR 411-086-0260 Pharmaceutical Services

Refer to F760

********************

Based on interview and record review it was determined the facility failed to follow physician orders for 1 of 3 sampled residents (#1) reviewed for respiratory care and bowel care. This placed other residents at risk for unmet needs. Findings include:

Resident 1 admitted to the facility in 7/2023 with diagnoses including congestive heart failure, emphysema and muscle weakness related to falls.

a. Resident 1's 7/17/23 care plan interventions for her/his respiratory symptoms included wearing a CPAP/BIPAP (a machine that regulates lung airflow and helps with breathing) while sleeping.

Physician Orders dated 7/18/23 instructed Resident 1 use a BIPAP one time a day related to sleep apnea.

Nursing assessments and notes revealed Resident 1 had a history of hypercapnia (high levels of carbon dioxide in the blood) and had not consistently used her/his CPAP while living at home.

Nursing notes dated 8/19/23, 8/20/23 and 8/21/23 revealed the CPAP machine's tubing was missing after she/he moved rooms. There was no documentation until 8/21/23 the facility attempted to replace the tubing.

A nursing note revealed on 8/22/23 at 3:06 AM Resident 1 was lethargic and would not wake up with verbal or physical stimuli. The on call physician was notified and the resident was sent to the ED and was found to be hypercapnic.

Resident 1 was not interviewed due to discharging from the facility.

On 8/29/23 at 11:45 AM, Staff 3 (RCM) confirmed the CPAP tubing was missing from 8/19/23 until Resident 1 was hospitalized on 8/22/23.

b. The facility's bowel care protocol was to administer laxatives to residents after two days of no bowel movement. Resident 1's physician orders followed this protocol.

Resident 1's 7/2023 and 8/2023 bowel records revealed she/he had no bowel movements from 7/19/23 through 7/24/23 and from 8/4/23 through 8/7/23.

The 7/2023 MAR revealed no Bisacodly (laxative) was administered to Resident 1 until 7/23/23, four days after her/his last bowel movement.

The 8/2023 MAR revealed no Bisacodly was administered until 8/7/23, three days after her/his last bowel movement.

On 8/29/23 at 11:45 AM, Staff 3 (RCM) confirmed the facility did not follow the bowel protocol.

*************************************
OAR 411-086-0110 Nursing Services: Resident Care

Refer to F684

**************************************

1. Based on interview and record review, it was determined the facility failed to follow physician orders for 1 of 3 (#4) residents sampled for physician orders. As a result, Resident 4 missed several doses of an anticoagulant (medication that prevents blood clots, which if not controlled could lead to heart attack or stroke), experienced a stroke and was hospitalized. The facility identified the noncompliance, immediately initiated a plan of correction, initiated in service training for staff providing services and care to residents with similar orders and completed audits to ensure resident safety. This incident was identified as meeting the criteria for past noncompliance. Findings include:

Resident 4 admitted to the facility on 9/28/22 with diagnoses including atrial fibrillation (a medical condition which causes the heart to beat too quickly) and congestive heart failure.

Resident 4's 5 Day MDS Assessment dated 12/13/22 revealed a BIMS score of 14 which indicated no cognitive impairment.

Resident 4's care plan dated 10/14/22 indicated Resident 4 was prescribed an anticoagulant medication related to atrial fibrillation.

The facility submitted a FRI on 10/21/22 which revealed Resident 4 had missed several scheduled doses of the anticoagulant due to an INR (International Normalized Ratio, a blood test that measured blood clotting, which determined how often blood thinners were administered) coding error in her/his TAR. As a result, Resident 4 experienced a stroke on 10/18/22 and required hospitalization.

The facility's investigation summary dated 10/24/22 and updated 10/26/22 revealed the following: Staff 5 (Former RN) stated she completed an INR check on Resident 4 on 10/11/22 and the result was 4.5 (a high count that could result in excessive bleeding). Staff 5 notified the physician who ordered the anticoagulant be held for two days and to recheck the INR on 10/15/22. Staff 5 stated while typing in the order she did not change the order type to "lab" which would have resulted in the order populating into the TAR and the order type was left as "other," which did not populate into the TAR. On 10/17/22, Staff 4 (RN) discovered the resident's INR check was not completed as ordered on 10/15/22. Staff 4 completed the lab which resulted in a low INR count (which indicated the blood had clotted and possibly caused a stroke). Staff 4 notified the physician, who ordered the anticoagulant be resumed. On 10/18/22 at approximately 6:30 PM, Resident 4 was observed to have symptoms of stroke and was sent to the hospital. The facility concluded the deficient practice resulted from the miscoded lab order, which prevented instructions to complete INR's to appear on the TAR.

Resident 4's medical chart was reviewed and the 10/2022 MAR revealed she/he did not receive anticoagulants from 10/11/22 through 10/17/22.

Physician Orders dated 10/11/22 revealed the anticoagulant was ordered to be held for two days and the next INR check be completed on 10/13/22. No INR checks were completed on 10/13/22 or 10/15/22.

Hospital records revealed Resident 4 was admitted to the Emergency Department on 10/18/22 with diagnoses of stroke and aphasia (inability to speak).

Staff 5 was not interviewed due to no longer working at the facility.

On 1/27/23 at 3:42 PM Staff 4 confirmed the facility's investigative findings and provided no additional information.

On 1/30/23 at 10:25 AM Staff 1 (Administrator) and Staff 2 (DNS) were notified of the investigative findings and provided no additional information.

The incident met the criteria for past non compliance as follows:

1. The incident indicated non compliance for F684.
2. The non compliance occurred after the exit date of the last standard recertification survey on 1/21/20 and before the date of the current survey, 1/25/22.
3. There was sufficient evidence the facility corrected the non compliance and was in substantial compliance with F684 as evidenced by:
-No deficient practice was found at F684 with additional sampled residents.
-The deficient practice was identified by the facility and the facility took immediate action to provide one on one counseling with the staff responsible for the coding error, provided in service training to all nursing staff for proper coding of orders and provided signature sheets verifying the nursing staff completed the training by 10/24/22.
-Daily audits were immediately implemented to ensure proper entries for orders related to anticoagulant medications with no deficient practice found.

2. Based on interview and record review, it was determined the facility failed to follow manufacturer instructions for heat pack application for 1 of 3 residents (#7) reviewed for wound care. This placed residents at risk for developing wounds. The facility identified the noncompliance, immediately initiated a plan of correction, initiated in service training for staff providing services and care to residents with similar orders and completed audits to ensure resident safety. These incidents were identified as meeting the criteria for past non compliance. Findings include:

Resident 7 admitted to the facility in 2017 with diagnoses including Multiple Sclerosis (MS) and quadriplegia.

Resident 7's Quarterly MDS dated 10/18/22 revealed a BIMS score of 15 which indicated no cognitive impairment.

Resident 7's care plan dated 10/20/22 revealed she/he had limited physical mobility related to her/his MS diagnosis and was totally dependent on staff for all ADL's. Resident 7 used an adaptive call light pad due to her/his mobility issues and was able to move her/his head to activate the call light.

The facility submitted a FRI on 5/14/20 which revealed on 5/12/20 Resident 7 had a blister on her/his right shoulder which was acquired from a heat pack applied to the shoulder on 5/12/20. The resident's physician was notified, the blister was treated and Staff 2 (DNS) reviewed heat pack procedures with all nurses on duty, with in service training implemented for all other nurses to review the procedure.

The facility's investigative summary dated 5/21/20 revealed the following: On 5/12/20 at 10:30 AM Staff 7 (Former RN) applied a heat pack to Resident 7's right shoulder. The call light was located on the resident's chest. At approximately 11:00 AM Resident 7 asked Staff 8 (Former CNA) to look at the shoulder area where the heat pack was applied because it hurt. Staff 8 removed the pack and observed the right shoulder area to be red. Later that evening Staff 9 (Former CNA) discovered the blister on Resident 7's right shoulder and notified Staff 18 (Former RN) who examined Resident 7. A blister was treated at the facility and the resident did not have any further complaints of pain. The facility determined the heat pack was not inspected every five minutes per manufacturer's recommendations due to Staff 7's report she was called away to another resident.

Nursing notes from 5/13/20 through 5/19/20 revealed the resident was seen by her/his physician, who ordered the heat pack discontinued. Orders were changed to apply topical cream to the resident's shoulder when she/he experienced pain and new protocols were implemented for all residents with orders for heat packs.

On 1/26/23 at 11:56 AM Staff 2 confirmed the facility's investigative findings and provided no additional information.

The incident met the criteria for past non compliance as follows:

1. The incident indicated non compliance for F684.
2. The non compliance occurred after the exit date of the last standard recertification survey on 1/21/20 and before the date of the current survey, 1/25/22.
3. There was sufficient evidence the facility corrected the non compliance and was in substantial compliance with F684 as evidenced by:
-No deficient practice was found at F684 with additional sampled residents.
-The deficient practice was identified by the facility and the facility took immediate action to provide one on one counseling with the staff responsible for not checking the heat pack every five minutes, provided in service training to all nursing staff, therapy staff and restorative aides responsible for heat pack application, provided signature sheets verifying the nursing staff completed the training and new protocols for testing water temperatures were implemented which ensured water temperatures were within manufacturer's recommended range.
-Audits of all residents with heat pack application orders were reviewed for safety and appropriateness. Orders were discontinued for any resident deemed inappropriate for continued heat pack use.

******************************************
OAR 411-086-0110 Nursing Services: Resident Care

Refer to F684

************************************************