Inspection Findings:
5. Resident 1 was admitted to the facility in 08/2017 with diagnoses including type II diabetes. During the survey, s/he was identified as having skin issues.Observations of Resident 1 during the survey revealed the resident was dependent on staff for most ADLs and used an air mattress while in bed.Clinical records, including progress notes from 07/04/22 to 09/26/22 and Resident Interim Service Plan (ISPs) were reviewed. The clinical record provided the following information:* On 07/30/22, placed on alert charting due to experience of delusion;* On 08/14/22, discontinued oxygen therapy;* On 08/28/22, redness on the right gluteus and an open area behind left ear; and* On 09/07/22, pulled catheter out.There was no documented evidence that the resident's short-term changes of condition and skin status were monitored, at least weekly, to resolution. On 09/28/22, the above findings were reviewed with Staff 2 (Interim ED), Staff 3 (Wellness Director/RN) and Staff 4 (Resident Care Coordinator). Staff acknowledged findings.6. Resident 3 was admitted to the facility in 05/2022 with diagnoses including Parkinson's disease and hypertension.Clinical records reviewed from 06/29/22 to 09/23/22 noted the following:* 08/19/22 - Staff documented carbidopa/levo (Parkinson's disease medication) was discontinued; and* 09/14/22 - Placed on alert charting due to high blood pressure.There was no documented evidence that the resident's short-term changes of condition were consistently monitored, at least weekly, to resolution. On 09/28/22, the above findings were reviewed with Staff 2 (Interim ED), Staff 3 (Wellness Director/RN) and Staff 4 (Resident Care Coordinator). Staff acknowledged findings.
2. Resident 6 was admitted to the facility in 06/2017, with diagnoses including dementia.Observations, interviews and review of Resident 6's clinical records revealed the following:Resident 6's service plan, dated 09/11/22, noted the following:* S/he shared an apartment with his/her spouse,* S/he displayed impairments in memory and judgement which interfered with daily functioning; * S/he did not always read social cues appropriately, "offering physical embrace, for example, to someone that did not desire it"; * S/he was not "able to recall when a person refused physical contact previously and could offer again"; and* Behavioral interventions included, Resident 6's spouse was to assist him/her with social situations and staff were to monitor Resident 6 anytime the spouse was not in the facility. * An incident report, dated 03/24/22, noted another resident reported Resident 6 had inappropriately touched him/her on the back and chest. An interim service plan, dated 03/28/2022, noted Resident 6 "needs to be with [spouse] at all times. Anytime staff sees [him/her] by [his/herself] please escort [him/her] to and from where [s/he] would like to go." There was no documented evidence the facility monitored the effectiveness of the intervention for spouse or staff escorts and/or had monitored the effectiveness of previous behavioral interventions for Resident 6. * An incident report, dated 09/14/22, indicated the same resident noted on 03/24/22, alleged Resident 6 had inappropriately touched and grabbed him/her again on his/her breast. An incident report dated 09/15/22, reviewed with the other resident's record, noted s/he was sent to the ER 09/15/22 and was diagnosed with a left breast contusion.There was no documented evidence the facility developed new interventions related to Resident 6's alleged behaviors of inappropriate physical contact with another resident and there was no documented evidence the facility monitored previous behavioral interventions for effectiveness.During an interview on 09/27/22, Staff 12 (MT) stated Resident 6's spouse usually escorted Resident 6 when they were out of the apartment together, but Resident 6 often did not remember to ask staff to escort him/her when the spouse was not available. During an interview with Resident 6 on 09/28/22, Resident 6 displayed symptoms of impaired cognition, had difficulty staying on topic and following the conversation and repeatedly provided the same answer which was not related to interview questions.On 09/28/22, staff were observed escorting Resident 6 and his/her spouse to and from the dining room and provided visual supervision during the lunch meal.The facility's failure to develop and monitor interventions to address Resident 6's repeated alleged behaviors placed other residents at risk of inappropriate physical contact with Resident 6.The need to ensure the facility developed and monitored interventions for effectiveness when residents experienced behavioral changes of condition was discussed with Staff 2 (Interim ED) on 09/27/22 and Staff 3 (Wellness Director/RN) and Staff 4 (Resident Care Coordinator) on 09/28/22. They acknowledged the findings and Staff 2 stated Resident 6's service plan was updated on 09/27/22, to include the use of a call pendant for Resident 6 and spouse to call staff for escorts to and from their apartment.3. Resident 4 was admitted to the facility in 11/2019, with diagnoses including anxiety and depression.Observations, interviews with staff and review of Resident 4's clinical records, revealed Resident 4 experienced the following changes of condition:* On 07/24/22, an alleged physical altercation with another resident;* On 07/24/22, Resident 4 self reported signs and symptoms of a "bad UIT [urinary track infection]"; and * On 08/03/22, behaviors related to alcohol intoxication and intrusive entrance into another resident's apartment. There was no documented evidence the facility determined resident specific interventions, or monitored the changes through resolution.The need to ensure the facility evaluated residents' changes of condition, determined and monitored interventions for effectiveness through condition resolution was discussed with Staff 2 (Interim ED), Staff 3 (Wellness Director/ RN) and Staff 4 (Resident Care Coordinator) on 09/28/22. They acknowledged the findings.4. Resident 7 was admitted to the facility in 04/2019, with diagnoses including macular degeneration and stroke.Observations, interviews with staff and review of Resident 7's clinical records indicated the following:*An investigation report, sent to APD on 07/25/22, noted another resident reported Resident 7 had pushed [him/her] on the shoulder enough to cause [him/her] to step back." Resident 7 denied ever touching the other resident.During observations and interview with Resident 7 on 09/28/22, the resident was alert and oriented and did not exhibit any behaviors. The need to ensure the facility developed and monitored interventions for effectiveness when residents experienced behavioral changes of condition was discussed with Staff 2 (Interim ED) on 09/28/22. He acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure resident changes of condition were evaluated, resident specific interventions were determined documented and monitored for effectiveness with weekly progress noted resolution for 6 of 7 sampled residents (#s 1, 2, 3, 4, 6 and 7) whose records were reviewed. Resident 6 had alleged behaviors of inappropriate touching of another resident. Resident 2 experienced severe weight loss. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 01/2022 with a diagnosis of congestive heart failure.During the acuity interview on 09/26/22, Resident 2 was identified to be at risk for weight loss.Review of Resident 2's charting notes, dated 06/29/22 through 09/26/22, interim service plans and weight records indicated the following:Resident 2's weights were noted as follows:*06/27/22 121 pounds;*07/15/22 113.6 pounds;*08/15/22 113 pounds; and*09/23/22 108.4 pounds.Between 06/27/22 and 07/15/22, Resident 2 lost 7.4 pounds or 6.1 % of his/her ideal body weight resulting in a severe weight loss.There was no documented evidence the facility evaluated Resident 2's weight loss including determining actions/interventions, referred to the facility RN or updated the service plan. Between 06/27/22 and 09/23/22 Resident 2 continued to lose a total of 12.6 pounds or 10.4 % of his/her body weight resulting in a severe loss in three months.Resident 2 was observed eating meals during breakfast and lunch on 09/27/22. The resident was able to eat meals without assistance, and consumed approximately 75% at each meal.During an interview on 09/28/22 with Staff 3 (Wellness Director/RN) she acknowledged the resident had experienced weight loss and there was no documented evidence an assessment had been completed.The facility failed to address the initial severe weight loss and the resident continued to lose weight. On 09/28/22, the Resident's weight loss was discussed with Staff 1 (Administrator) and Staff 2 (Interim ED). They acknowledged the findings.
Plan of Correction:
OAR 411-054-0040 (1-2) Change of Condition and Monitoring1. What actions will be taken to correct the rule violation for each example/resident?a. Resident 2 chart will be reviewed by RN for weight history. Evaluation and care plan will be reviewed and updated to reflect weight loss including interventions and direction to the staff.b. Communication will be initiated with physician and family regarding resident 2 weight loss. c. Physician orders will be implemented when received regarding interventions for weight loss.d. An audit of the past 6 months will be conducted on all residents to identify any weight changes. All changes above 3% will be reported to the physician and care plan will be updated to reflect interventions for identified reisdents with weight loss/gain.e. Resident 4, 6 and 7 chart and care plan will be reviewed by RN and updated to include identification of behaviors, interventions to be put in place and notification to physician. f. Behavior monitoring and a behavior strategy plan will be developed and put in place for both residents.g. Resident 1 and 3 chart and care plan will be reviewed by RN and updated to accurately include identification of changes in condition.h. RN will enter updated change of condition notation on each resident.2. How will the system be corrected so this violation will not happen again. a. RN will attend the Oregon Role of the RN class.b. All care staff will be trained on change of condition identifiers, signs of weight loss/gain, monthly resident weight protocols, recording of weights in resident chart and reporting variations.c. Care staff will enter monthly weights into QMAR by the 7th of each month. The RN will print a weight report monthly and review weights on all residents.d. RN will address any weight fluctuations above 3% in any given 3 month period. e. RN will make weekly chart notes on each resident with a change of condition until stable. f. RN and Executive Director will have weekly one on one meetings to discuss residents at risk, resident changes and coordination of care.g. All residents with change of condition needs will be discussed in SMART meeting daily Monday through Friday to ensure COC has been addressed.h. All residents identified as having a change of condition will be placed on alert charting for monitoring and an ISP will be put in place for care staff to review at the beginning of each shift until the RN can evaluate the change and update the care plan to reflect new needs. ISP's are reviewed daily Monday throught Friday during the SMART meeting.i. Installation of a white board in the RN office to track resident change of conditions. HIPPA will be maintained.3. How often will the area needing correction be evaluated? a. Weekly during ED and RN one on one meetings to review residents at risk, resident changes and coord. of care, including review of weekly notes on residents with changes.4. Who will be responsible to see that the corrections are completed/monitored?a. ED and RN during weekly one on one meetings.b. ED during daily SMART meetings. Minutes from these meetings will be maintained on the Seasons dashboard.