Hopewell House

1. The identified incident was immediately reported to Adult Protective Services (APS) via email on 2/12 when it was discovered by the surveyor. APS asked for specific information/documentation and this was sent via email on 2/13. An APS investigator came to Hopewell House on 2/14 for an in-person investigation. The Executive Director and Resident were both interviewed. We are currently awaiting the outcome of the APS investigation (we were informed it would be 2-6 months before we receive the report). The resident in question was interviewed and reported feeling safe and well cared for. After full review of the resident chart notes, which have a nursing note on every shift, it was noted that the same day of the incident, the resident recounted the incident with our med tech and stated "I am ok now. It's over", and her mood was cheerful with normal eating and drinking. 2. As it is standard policy for all staff to report incidents in a timely manner and to understand the process, it is imperative that these systems are reviewed. Incident reporting was reviewed at the All-staff meeting (2/21/24) as well as the next clinical team meeting (3/1/24). This is a full review of when to report, how to report, and who gets notified. This will be inclusive of screenshots from ECP, our EMR to demonstrate exactly where the incident report is found and how to complete it properly. In addition to further teaching and training, the policy and procedure will be reviewed and updated to reflect step by step instructions for staff. An alert has been turned on in the EMR to notify the Health Services Director (HSD) and Executive Director (ED) whenever an incident report is created to ensure immediate notification to appropriate administration.3. HSD and ED will read all clinical notes from the previous day in the morning (and weekend notes on Monday AM) to stay up to date on potential issues that may have been missed. A "team huddle" will be implemented each morning to review a standard set of data from the previous day (incidents, med changes, outside provider notes, etc). This daily huddle began on 2/26/24. 4. The Executive Director/Administrator will be responsible to ensure that all the corrections are completed and monitored.

1. Due to the flagged incident not being reported correctly at the time, the appropriate change of condition was not clearly documented and therefore was not specifically monitored per OAR C270. In review of the daily documentation and in accordance with current policy and practice, the resident was monitored by nursing staff on each shift and nursing documentation was completed accordingly. While we cannot correct the prior lack of clear identification of change of condition and necessary monitoring to that specific incident, we are able to identify through a full review of the record on 2/14/24 that nursing staff (RNs and LPNs) continued to evaluate and monitor resident around-the-clock with corresponding clinical nursing documentation of resident's overall condition three times per day every day of the week.2. We have evaluated and updated our change of condition and monitoring written policy, to ensure systems are in place to prevent this violation from happening again. Along with incident reporting, change of condition and associated monitoring requirements will be reviewed in the clinical staff meeting on 3/1/24 to ensure understanding of the process by all clinical team members. HSD has reviewed and updated the Resident Monitoring and Reporting policy and procedure to include documentation of identified change of condition in EMR and notification of Health Services Director if indicated, to ensure that proper monitoring needs are identified and followed through with until resolution. 3. With new systems in place to ensure proper notification regarding incidents, including auto alert through the EMR to the HSD and ED, daily review of clinical notes by the HSD and ED, and daily "team huddle" to review standard set of data, administration will be able to regularly assess that proper monitoring is completed for all incidents and changes. 4. The Health Services Director is responsible to ensure that all the corrections are completed and monitored.

1. As it relates to tag C303 (a), identification of administration of medication different than prescribed order (resident was administered 5mg of Diazepam, rather than 10mg as ordered, per resident request for ½ dose) was identified on 02/12/24. Upon identification and discussion with Hospice, a new order was immediately requested to reflect correct resident-requested dosing. Updated signed orders were received on 02/13/24.As it relates to tag C303 (b), all medication administration records for medications not administered on dates cited were reviewed. For citation on 01/12/24, Pantoprazole (for acid reflux) was given on 1/11, not given on 1/12, and given on 1/13. Medication refill had been requested from Hospice but did not arrive until evening of 1/12 and therefore one dose was missed. For citation on 01/29/24, Atropine-Dihenoxylate (for diarrhea output) was given on 01/29 at 10:32am, noted to be last tablet remaining and awaiting delivery from pharmacy, not given on 01/29 at 10:36pm, noted to have not yet been delivered by pharmacy, then given on 01/30 at 12:14am after pharmacy delivery arrived. For citation on 01/30/24, Methadone (for pain) was given in tablet form at scheduled time, however the liquid ordered had not yet arrived from the pharmacy, therefore the resident did not miss a dose of the medication but the pharmacy had indeed not yet delivered the liquid form of the medication. As this rule violation occurred in the past, corrective action is focused on modification of policy and staff education to ensure systemic correction.2. As it relates to tag C303 (a) Staff education provided in clinical staff meeting on 03/01/24, regarding adherence to medication administration and treatment orders, and collaboration with Hospice partners for order updates when resident preferences or needs change. As it relates to tag C303 (b), Re-ordering Medication policy reviewed and updated to reflect procedure for requesting medication refills, including 7-day timeline for refill requests, tracking staff communications with Hospice and/or pharmacy, and timeline for STAT medication requests to ensure timely delivery of medications. Staff education provided in clinical staff meeting on 03/01/24, regarding updates as it pertains to Re-ordering Medication policy and procedures.A large white board in the medication room displays medications due for refill and tracks the progress, so that the procedure can be followed when medications do not arrive in a timely manner. 3. As it relates to tag C303 (a), Health Services Director will evaluate medication and treatment orders daily and ensure orders are being followed and Hospice is being notified of need for updated orders if indicated. As it relates to tag C303 (b), Health Services Director will huddle with day shift staff Monday - Friday to review medication delivery requests, expected delivery date, and follow-up needed if applicable.4. Health Services Director is responsible to ensure that all the corrections are completed and monitored.

1. The resident was evaluated by facility RN/Health Services Director for self-administration of over-the-counter medication (Imodium), and this documentation was included in the resident's MAR. However, on 02/12/24, surveyor identified that a prescriber's order approving self-administration is required. Health Services Director immediately notified Hospice and on 02/12, an order was obtained stating self-administration of Immodium is approved and that the resident may keep this medication at their bedside. MAR was updated accordingly with the prescriber's orders. Additionally, on 02/13/24, surveyor noted that while patient had a prescriber's orders for a PCA (Patient Controlled Analgesia) pump for continuous IV administration of pain medication, this requires an additional order from prescriber for self-administration due to the ability of resident to push a nurse-programmed, but patient-controlled button, that allows for a fixed amount of medication to be administered for additional pain control. Hospice was immediately notified, and order was obtained on 02/15/24, clarifying approval of resident use of PCA for both continuous and bolus dosing of medication. MAR was updated accordingly with the prescriber's orders.2. The Self-Medication Administration assessment form that is utilized by RN for evaluation of a resident's ability to safely self-administer medications was updated to include "MD order obtained" as a checkbox, to ensure any resident who is screened for self-administration in the future also has a corresponding order of approval from the following MD/prescriber. Additionally, the standard order set, which includes facility- and resident-specific orders for every resident admitting to Hopewell House, was updated to include instruction to Hospice providers, "For self-administered medications, including PCA pumps, MD order required," to ensure both Hospice partners and staff are aware of this requirement for all self-administration of medications.3. Every new admission to Hopewell House will be assessed by RN/Health Services Director for self-administration of medications if resident expresses a preference to self-administer medications or is using a PCA pump for end-of-life pain management. Each admission will be audited by HSD to ensure that resident has been evaluated for the ability to safely administer medications and, if so, has a corresponding order from Hospice. Additionally, with daily medication order reviews completed by HSD, any new orders for self-administration will be double-checked to conversely ensure appropriate nursing documentation is in place showing the resident has been screened for safety of self-administration.4. The Health Services Director is responsible to ensure that all the corrections are completed and monitored.

1. While we have appropriately conducted our fire drills every other month routinely, timed evacuation has not been completed with our resident population due to their hospice/end of life status, and the significant disruption it would create. To correct this omission on our fire drills, we will now conduct simulated evacuations with volunteers or staff members standing in as residents as per surveyor recommendation. The first timed simulated evacuation was completed on 2/28/24. 2. We will alternate during drills between timing a wheelchair evacuation and a full hospital bed evacuation. We conducted our first timed evacuation on our Feb 28th drill and then will complete another in early March 2024 to ensure compliance. Our fire drill form was amended on 2/26/24 to explicitly include instructions for simulated timed evacuations so this is NOT missed during a drill, no matter who is leading it. 3. This will be a regular part of our drill routine when drills are conducted every other month going forward. 4. The Executive Director/Administrator will be the responsible staff person to make sure this is monitored and completed.