Marquis Wilsonville Post Acute Rehab

In the surveyor’s words

From the most serious findings on record at Marquis Wilsonville Post Acute Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Oct 14, 2022

  1. Based on interview and record review it was determined the facility failed to ensure emergency services were summoned and interventions provided upon a resident's significant change in condition for 1 of 3 sampled residents (#1) reviewed for change of condition. Resident 1 had a significant change of condition, was not provided medical interventions, emergency services were not summoned and she/he died . Findings include: Resident 1 was admitted to the facility in 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 1's POLST (Portable Orders for Life-Sustaining Treatment) indicated the resident did not want to be resuscitated if she/he did not have respirations or a pulse, but wanted to be transported to the hospital if indicated. […]

• Actual harm, isolatedF756Oct 14, 2022

  Based on interview and record review it was determined the facility failed to ensure a pharmacy recommendation was acted upon to ensure a laboratory test was obtained for 1 of 3 sampled residents (#4) reviewed for change in condition. Resident 4 was admitted to the hospital with a gastrointestinal (stomach/intestinal) bleed. Findings include: Resident 4 was admitted to the facility in 2022 with diagnoses included an infected knee replacement. Per Online Epocrates (web based medication reference): [MEDICATION(S)] (antibiotic) and [MEDICATION(S)] (prevents clots)-Avoid combination: combination may decrease [MEDICATION(S)] levels, efficacy; may increase risk of bleeding, including life-threatening affects. […]

• Actual harm, isolatedF760Apr 30, 2021

  Based on interview and record review it was determined the facility failed to ensure a snack or meal was provided in a timely manner after rapid-acting insulin was administered for 1 of 1 sampled resident (#33) reviewed for medication errors. This failure resulted in Resident 33 experiencing a severe hypoglycemic (low blood sugar) event requiring emergency medical services and treatment at the hospital. Findings include: Resident 33 was admitted to the facility in 3/2021 and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 33 received Novolog insulin which the manufacturer identified as an injectable rapid acting insulin used to lower blood glucose and was administered subcutaneously within 5-10 minutes before a meal. […]

• No harm, potential for more than minimal, widespreadF727Apr 30, 2021

  Based on interview and record review it was determined the facility failed to ensure adequate RN staffing for 5 of 29 days reviewed for sufficient RN staffing. This placed residents at risk for unmet medical needs. Findings include: A review of the facility's Direct Care Staff Daily Reports from 4/1/21 through 4/29/21 revealed five days without RN coverage on any shift. The identified dates were: - 4/3/21 - 4/5/21 - 4/11/21 - 4/17/21 - 4/25/21 During an interview on 4/30/21 at 11:23 AM with Staff 1 (Administrator) and Staff 3 (Staffing Director), the staff acknowledged the lack of RN coverage on the identified dates.

• No harm, potential for more than minimal, patternF578Jul 15, 2022

  Based on interview and record review, it was determined the facility failed to develop and implement policies and procedures regarding residents' rights to formulate an advanced directive for 6 of 6 sampled residents (#s 4, 7, 19, 21, 22 and 24) reviewed for advanced directives. This placed residents at risk for not having their health care preferences honored. Findings include: Records reviewed for Residents 4, 7, 19, 21, 22, and 24 revealed no documentation of an advance directive or documentation to indicate the residents were informed of or provided written information concerning their right to formulate an advance directive. […]