Jim and Patti Jones Assisted Living Home III

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area from which a resident could exit to a location at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if facility staff were unaware of the egress of a resident from the facility. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. During the environmental tour, the Compliance Officer observed the front door leading to the street from the facility. However, the door was not secured and the door chime was not functioning. 3. During the environmental tour, the Compliance Officer observed the door leading out to the backyard from R3's bedroom. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. The door was not equipped with a device that alerted caregivers of the egress of a resident. 4. During the environmental tour, the Compliance Officer observed a french door located in the living room leading to the back yard. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. However, the door was not secured and the door chime was not functioning. 5. During the environmental tour, the Compliance Officer observed a door located between a hallway and resident rooms leading to the back yard. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. However, the door was not secured and the door chime was not functioning. 6. A review of facility documentation revealed a policy titled "Protocol For Wandering Residents," the policy stated "There is a means of existing the Facility ... Provides access to an outside area that allows the residents to be at least 30 feet away from the facility, and controls or alerts personnel of the egress of a resident from the facility." 7. In an interview, E1 and E2 acknowledged a means of exiting the facility to an outside area did not control or alert employees of the egress of a resident from the facility.

Based on documentation review, observation, and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected and sensitive resident health information being disclosed without the resident's consent or knowledge. Findings include: 1. A.R.S. \'a7 12-2291(6) "Medical records" means all communications related to a patient's physical or mental health or condition that are recorded in any form or medium and that are maintained for purposes of patient diagnosis or treatment, including medical records that are prepared by a health care provider or by other providers. 2. During the environmental tour, the Compliance Officer observed resident medical records sitting unsecured on several bookshelves situated along the right-hand side of a room accessible from the facility's entrance. Additionally, the Compliance Officer observed electronic medical records were displayed on an unattended computer screen within the same room. 3. A review of facility documentation revealed a policy titled "Medical record Maintenance," the policy stated "A manager shall ensure that a resident's medical record is protected from loss, damage or unauthorized use." 4. In an interview, E1 and E2 acknowledged resident medical records were not protected from loss, damage, or unauthorized use.