Helping Hands Assisted Living

Based on record review and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of E1's personnel record revealed no documentation indicating E1 completed fall prevention and fall recovery training. 2. Review of E2's personnel record revealed no documentation indicating E2 completed fall prevention and fall recovery training. 3. During an interview, E1 acknowledged documentation was not available showing E1 and E2 had completed fall prevention and fall recovery training.

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R1's medical record revealed a current written service plan for personal care services dated February 25, 2023. This service plan stated the following services were needed: "Sufficient Fluids, snacks offered throughout the day" "Incontinent Bowel/Bladder Incontinent checks q2-3 hrs, change PRN" However, documentation was not available indicating these services were provided April 1st - present. 2. Review of R2's medical record revealed a current written service plan for personal care services dated December 20, 2022. This service plan stated the following services were needed: "Sufficient Daily fluids and protein offered mealtimes/throughout day" However, documentation was not available indicating this service was provided April 1st - present. 3. During an interview, E1 acknowledged R1's and R2's medical records did not include documentation of the above listed services and reported the services were provided as indicated in the service plan.

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 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 refused the pneumonia vaccination March 28, 2022. However, current documentation was not available showing the pneumonia vaccination was offered or received. Based on R2's acceptance date, this documentation was required. 3. During an interview, E1 acknowledged R2's medical record did not include current documentation showing the pneumonia vaccination was offered or received.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of two residents reviewed. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. Review of R1's medical record revealed a current written service plan dated February 25, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed a signed medication order dated March 29, 2023. This medication order stated "Olanzapine 10mg tablet 1 tablet bedtime oral ". 3. Review of R1's medical record revealed an April 2023 medication administration record (MAR). This MAR stated "Olanzapine 10mg tab QD PO". However, did not include documentation Olanzapine 10mg was administered April 1st - present. 4. During an observation of R1's medications, Olanzapine 10mg was observed and one tab was observed prefilled in the "Bed" slot of R1's medication organizer. 5. During an interview, E1 reported one tab of Olanzapine 10mg was administered per the medication order and acknowledged R1's medical record did not include documentation the medication was administered.