Pearl Manor Assisted Living

Based on documentation review, record review, and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery including initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented. Findings include: 1. A review of facility documentation revealed a training program titled "Falls Prevention and Fall Recovery Training" (dated April 1, 2023). However, the training program did not include initial training and continued competency training. 2. In an interview, E1 acknowledged the facility's training program for fall prevention and fall recovery did not include the initial training and continued competency training component. 3. A review of E1's personnel record revealed completed initial training in fall prevention and fall recovery (dated December 2, 2021). However, continued competency training was not available for review. 4. In an interview, E1 reported the training documentation dated in December 2, 2021 was the only documentation available.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of the individual's completed in-service education required by policies and procedures, for one of three personnel members sampled. Findings include: R9-10-101.116. "In-service education" means organized instruction or information that is related to physical health services or behavioral health services and that is provided to a medical staff member, personnel member, employee, or volunteer. 1. A review of facility documentation revealed a policy and procedure titled "Orientation, In-Service Trainings for Employees" (dated April 1, 2023). The policy and procedure stated " ... 2. The facility must ensure that staff demonstrate competency in the skills and techniques they are expected to perform prior to providing any direct care to the residents." 2. A review of R1's medical record revealed a service plan for directed care services (dated in 2023). The service plan stated " ... Indwelling catheter ... Empty Drainage Bag Every 8 Hours." 3. A review of R1's medical record revealed an activities of daily living (ADL) sheet for February 2024. The ADL sheet documented E2 provided "Catheter Care" to R1 on February 1-29, 2024. 4. A review of E2's (hired in 2020) personnel record revealed E2 was hired as a caregiver. However, documentation of in-service education in "Catheter Care" was not available for review. 5. In an interview, E4 reported E4 trained E2 in "Catheter Care." E4 reported E4 did not document the training. 6. In an interview, E1 acknowledged in-service education for E2 was not available for review.

Based on record review and interview, the manager failed to ensure a service plan for a resident receiving personal care services included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; and offering sufficient fluids to maintain hydration, for one of one resident sampled who received personal care services. The deficient practice posed a risk as the service plan did not include services to be provided to a resident. Findings include: 1. A review of R2's medical record revealed a service plan for personal care services (dated in 2023). However, the service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; and offering sufficient fluids to maintain hydration. 2. In an interview, E1 acknowledged R2's service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; and offering sufficient fluids to maintain hydration.

Based on record review and interview, the manager failed to ensure a service plan for a resident receiving directed care services included the requirements in R9-10-814(F)(1) through (2), for one of one resident sampled who received directed care services. The deficient practice posed a risk as the service plan did not include services to be provided to a resident. Findings include: R9-10-814(F)(1)(2) In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving personal care services includes: 1. Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; 2. Offering sufficient fluids to maintain hydration. 1. A review of R1's medical record revealed a service plan for directed care services (dated in 2023). However, the service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; and offering sufficient fluids to maintain hydration. 2. In an interview, E1 acknowledged R1's service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; and offering sufficient fluids to maintain hydration.

Based on documentation review, record review, and interview, the manager failed to ensure an individual who administered an opioid in treating a patient documented in the patient's medical record an identification of the patient's need for the opioid before the opioid was administered, and the effect of the opioid administered for a prescribed opioid was provided, for one of one sampled resident who was administered an opioid. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Administering Opioids in Assisted Living Setting" (dated April 1, 2023). The policy and procedure stated " ... 1. Before administering an opioid in compliance with an order as part of the treatment of a resident, identifies to resident's pain before the opioid is administered; 2. Monitors the resident's response to the opioid, and 3. Documents in the resident's medical record: a. An identification of the resident's pain before the opioid was administered, and b. The effect of the opioid administered." 2. A review of R2's (accepted in 2022) medical record revealed a service plan for personal care services (dated in December 2023). The service plan revealed R2 received medication administration. 3. A review of R2's medical record revealed documentation stating R2 had an end of life condition or an active malignancy was not available for review. 4. A review of R2's medical record revealed a medication order (dated September 8, 2023) for "HYDROcodone-Acetaminophen 7.5-325 MG Tablet ... 1 tablet Orally every 6 hours ..." 5. A review of R2's medical record revealed a medication administration record (MAR) dated February 2024. The MAR documented R2 received Hydrocodone-Acetaminophen on February 1-29, 2024. However, the MAR did not document an identification of R2's need for the opioid before the opioid was administered, and the effect of the opioid administered. 6. In an interview, E2 reported R2's pain level was not documented. E2 reported E2 did not document the need for an opioid before the opioid was administered and the effect of the opioid was administered for routine opioids. 7. In an interview, E1 acknowledged an identification of R2's need for the opioid before the opioid was administered, and the effect of the opioid administered was not documented.