rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
1,"BURNS NURSING HOME, INC.",15009,701 MONROE STREET NW,RUSSELLVILLE,AL,35653,2018-08-01,880,D,0,1,XRXN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of a facility policy titled Infection Prevention and Control Program/Plan, the facility failed to ensure a Certified Nursing Assistant (CNA) performed hand hygiene between removing a pair of soiled gloves and re-gloving during incontinence care. This affected Resident Identifier (RI) #12, one of one resident observed during incontinence care. Findings include: RI #12 was readmitted to the facility on [DATE]. Review of RI #12's quarterly Minimum Data Set assessment, with an Assessment Reference Date of 7/02/18, revealed RI #12 had severely impaired cognition and required extensive assistance of one person for toileting and personal hygiene needs. RI #12 was always incontinent of both bowel and bladder. A facility policy titled, Infection Prevention and Control Program/Plan, revised (MONTH) (YEAR), revealed: Policy: It is the policy of this facility to establish and maintain an Infection Prevention and Control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy Explanation and Compliance Guidelines: . 4. Hand Hygiene Protocol: a. All staff shall wash their hands . after PPE (personal protective equipment) removal . Incontinence care for RI #12 was observed on 07/31/18 at 04:17 PM. Incontinence care was performed by Employee Identifier (EI)#3 and EI#4, both CNAs. During the care, while cleaning RI#12's bottom, EI#3 had stool on her glove. EI#3 removed the soiled glove and put on a new pair without doing hand hygiene. When EI#3 was finished wiping RI #12, she changed gloves again and did not do hand hygiene. An interview conducted with EI#3 on 07/31/18 at 04:35 PM. EI#3 was asked what should be done between removing soiled gloves and putting on a new pair. EI#3 replied, use germ x (sanitizer). EI#3 was asked if she did that every time she changed her gloved during the care. EI#3 said she did not think so. On 8/01/18 at 11:10 AM, the Infection Control Nurse, EI #5, was interviewed. EI #5 was asked what should be done after removing soiled gloves, before putting on a new pair. EI#5 replied, wash hands or use hand sanitizer. EI #5 said if that was not done, it could cause harm.",2020-09-01
2,"BURNS NURSING HOME, INC.",15009,701 MONROE STREET NW,RUSSELLVILLE,AL,35653,2019-08-21,554,D,0,1,HHU111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review and review of facility policies titled, MEDICATION ADMINISTRATION BY MOUTH and Self-Administration of Medication, the facility failed to ensure a licensed nurse remained with Resident Identifier (RI) #32, who had not been assessed for self-administration of medication, during the administration of [MEDICATION NAME] during medication pass observation on 08/21/19. This affected RI #32, one of four residents observed during medication pass observation and one of two nurses observed. Findings Included: A review of a facility policy titled, MEDICATION ADMINISTRATION BY MOUTH, with a REVISED DATE: 09/18/2014, documented: .9. The nurse will remain with resident/patient until medications are taken. A review of a facility policy titled, Self-Administration of Medication, with Date Implemented: (MONTH) (YEAR), revealed: .1.an assessment is conducted by the interdisciplinary team and results of the assessment are recorded on the Self-Administration Assessment Form, which is placed in the resident's medical record. 2. As part of the interdisciplinary team, a physician order [REDACTED]. The care plan must reflect resident self-administration and storage arrangements for such medications. RI #32 was admitted to the facility on [DATE]. A review of RI #32's medical record revealed no order for self-administration of any medications, no self-administration assessment form and no care plan for self-administration of medication. On 08/21/19 at 7:56 a.m., during medication pass observation, the surveyor observed Employee Identifier (EI) #1, Licensed Practical Nurse (LPN), mix RI #32's [MEDICATION NAME] in four ounces of water in a plastic cup and deliver it RI #32's bedside, along with other medications. EI #1 administered all medications except [MEDICATION NAME]. Surveyor observed EI #1 instruct RI #32 to drink his [MEDICATION NAME]. EI #1 then left RI #32's bedside and entered the bathroom to wash her hands out of direct sight of RI #32. When EI #1 returned to the bedside, RI #32 handed her three plastic cups, two that contained liquid in them. EI #1 did not question RI #32 about the liquid remaining in the cups or if he/she had taken the [MEDICATION NAME]. On 08/21/19 at 1:31 p.m., an interview was conducted with EI #1, LPN. EI #1 was asked how long should she remain with a resident when administering medications. EI #1 said, until they get completely done. EI #1 was asked did she remain with RI #32 while he/she drank the water that [MEDICATION NAME] was mixed in. EI #1 responded she did not guess she did. EI #1 was asked, did RI #32 have an order to self-administer medications. EI #1 said no. EI #1 was asked had RI #32 been assessed to self-administer medications. EI #1 replied she did not think so. EI #1 was asked was RI #32 care planned for self-administration of medications. EI #1 replied not that she knew of and she had not seen it if he/she was. When asked what was the concern with not remaining with a resident until all medication was consumed or administered, EI #1 answered, somebody else could have gotten it or he/she could not have taken it. On 08/21/19 at 4:18 p.m., an interview was conducted with EI #2, Registered Nurse (RN)/Infection Control Preventionist/Minimum Data Set (MDS) Coordinator. EI #2 was asked how long should a nurse remain with a resident during medication administration. EI #2 said until all the medicines are taken. EI #2 was asked what should be in place before a resident can safely self-administer medications. EI #2 replied, an assessment form, physician order [REDACTED]. EI #2 was asked what was the concern with a resident self-administering medications without the proper assessment, physician's orders [REDACTED]. EI #2 answered, they could get the wrong dose, the wrong time or if it was left somebody could come by and pick it up that did not need it and the resident it was intended for may not get it.",2020-09-01
3,"BURNS NURSING HOME, INC.",15009,701 MONROE STREET NW,RUSSELLVILLE,AL,35653,2019-08-21,880,D,0,1,HHU111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, medical record review and review of Potter and Perry, Fundamentals of Nursing, Ninth Edition, the facility failed to ensure a licensed nurse: 1. cleaned Resident Identifier (RI) #32's nasal spray prior to recapping, 2. removed gloves and washed hands and applied clean gloves after administering RI #32's inhaler prior to administering his/her nasal spray, 3. cleaned RI #32's inhaler prior to recapping, 4. cleaned RI #32's [MEDICATION NAME] syringe prior to placing it back in a plastic sleeve, and 5. cleaned and dried RI #32's nebulizer mask and reservoir prior to storing it in a plastic bag. This affected RI #32, one of four residents observed during medication pass observation and one of two nurses observed. Findings Included: A review of of Potter and Perry, Fundamentals of Nursing, Ninth Edition, Chapter 29, Infection Prevention and Control, page 455, documented: .Cleaning. Cleaning is the removal of organic material .from objects and surfaces .When an object comes in contact with an infectious or potentially infectious material, it is contaminated .Reusable objects need to be cleaned thoroughly before reuse . RI #32 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 08/21/19 at 7:56 a.m., during medication pass observation, Employee Identifier (EI) #1, Licensed Practical Nurse (LPN), was observed administering RI #32's inhaler while wearing gloves. She then proceeded to administer RI #32's nasal spray while wearing those same gloves. EI #1 also recapped RI #32's nasal spray and inhaler without wiping or rinsing them off and returned a syringe used to administer RI #32's sublingual [MEDICATION NAME] back into a plastic sleeve without rinsing it prior to storing it in the medication cart. EI #1 was then observed returning RI #32's nebulizer mask and tubing back into a plastic bag without emptying the residue, rinsing and drying the reservoir. On 08/21/19 at 1:31 p.m., an interview was conducted with EI #1, LPN. EI #1 was asked what should she do after a resident has used an inhaler. EI #1 said wipe it off with a Kleenex or something like that. EI #1 was asked what should she do after a resident has used a nasal spray. EI #1 replied, same thing, wipe it off with a Kleenex or something. EI #1 was asked did she clean the inhaler before placing the cap back on it and storing it in the medication cart. EI #1 responded, no. EI #1 was asked did she clean the nasal spray after administering it to RI #32. EI #1 said no. When asked when she should wash her hands and change gloves during medication pass with different routes, EI #1 stated after each route. EI #1 was asked did she remove her gloves, wash her hands and apply clean gloves after administering RI #32's inhaler, before administering his/her nasal spray. EI #1 said no, she should have removed her gloves and went and washed them right then and put on a clean pair. EI #1 was asked did she clean the syringe used to administer RI #32's [MEDICATION NAME] before returning it to the medication cart. EI #1 replied no. EI #1 was asked what should she do after administering a nebulizer treatment before storing the tubing and pipe back in the plastic bag. EI #1 said she should have wiped it. EI #1 was asked did she pour out the residue after RI #32's treatment. EI #1 stated no. EI #1 was asked what was the concern with these issues. EI #1 answered infection control. On 08/21/19 at 4:18 p.m., an interview was conducted with EI #2, Registered Nurse/Infection Control Preventionist. EI #2 was asked, when should a nurse change gloves and wash her hands during medication pass. EI #2 said, before she goes in, after she finishes and each time she goes from one route to another she should change her gloves and wash her hands or at any time she was not sure if she had touched something. EI #2 was asked, what should a nurse do with an inhaler and/or nasal spray bottle after administration and prior to storing back in the medication cart. EI #2 replied, wipe or wash the mouthpiece or nasal tip if needed before placing it back in the plastic bag. EI #2 was asked, what should a nurse do after administering [MEDICATION NAME] sulfate by a syringe prior to storing it in the container. EI #2 replied, wash it and dry it and put it back in the container. EI #2 was asked what was the concern with not washing hands or changing gloves when needed or not cleaning inhalers, nasal sprays, nebulizer pipes and reservoirs prior to them being stored. EI #2 answered, spread of bacteria and infections.",2020-09-01
4,COOSA VALLEY HEALTHCARE CENTER,15010,260 WEST WALNUT STREET,SYLACAUGA,AL,35150,2017-04-06,241,D,0,1,0F3P11,"Based on observations, interviews and review of a facility policy titled Promoting /Maintaining Resident Dignity, the facility failed to ensure staff knocked on residents' doors prior to entering the residents room. This was observed on three of four days of the survey, affected Room Locator (RL) #1, RL #2, RL #3, RL #4, RI #5 and affected two of three units in the facility. Findings Include: A review of a facility policy titled Promoting /Maintaining Resident Dignity, with a revision date of 8/15/15 documented the following: POLICY: It is the practice of this facility to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect. Compliance Guidelines: .11. Respect the resident's living space, personal possessions. Knock on door prior to entering room . On 4/3/17 at 7:00 p.m., the surveyor observed Employee Identifier (EI) #10 walk into RL #1, then walk into RL #2, and then walk into RL #3 without knocking. On 4/4/17 at 12:05 p.m., the surveyor observed EI #11 walk into RL #4 without knocking. On 4/5/2017 at 11:05 a.m., the surveyor was conducting a resident interview with EI #5 and observed a staff member enter RL #5 without knocking. On 4/6/17 at 2:10 p.m., an interview was conducted with EI #11, a Registered Nurse (RN). EI #11 was asked if she remembered entering RL #4 without knocking. EI #11 replied, yes. EI #11 was asked how was she trained to enter a resident's room. EI #11 replied, to knock first. EI #11 was asked what was the facility's policy on entering a residents room. EI #11 replied, to knock first. On 4/6/17 at 3:15 p.m., an interview was conducted with EI #10, a Certified Nursing Assistant (CNA). EI #10 was asked how she was trained as a CNA to enter a resident's room. EI #10 replied, to knock then wait for them to give permission to come in. EI #10 was asked what was the facility's policy on how to enter a resident's room. EI #10 replied, to knock and wait for permission to come in. The surveyor asked EI #10 what type of issue was it to enter a resident's room without knocking. EI #10 replied, a dignity issue. On 4/6/17 at 3:40 p.m., an interview was conducted with EI #12, a Licensed Practical Nurse (LPN). EI #12 was asked if she remembered entering RI #5's room yesterday while the surveyor was in the room. EI #12 replied, yes. EI #12 was asked if she knocked on the door before entering. EI #12 replied, she thought she did. EI #12 was asked what was the training the facility gave in regards to entering a resident's room. EI #12 replied knock and wait for acknowledgement. EI #12 was asked what was the policy upon entering a resident's room. EI #12 replied, knock and introduce yourself. EI #12 was asked what was the potential harm of not knocking when entering a resident's room. EI #12 replied, being disrespectful and invading their privacy.",2020-09-01
5,COOSA VALLEY HEALTHCARE CENTER,15010,260 WEST WALNUT STREET,SYLACAUGA,AL,35150,2017-04-06,253,D,0,1,0F3P11,"Based on observations, interview and review of a facility document titled Cart List, the facility failed to ensure a plaster like substance was not hanging from the dining room ceiling on three of four days of the survey. This had the potential to affect 13 of 74 residents who eat meals in the dining room. Findings Include: On 4/4/17 at 8:07 a.m., and 12:35 p.m., the surveyor observed a plaster like substance hanging from the ceiling in the dining room. At 12:35 p.m., the surveyor observed a resident sitting under the ceiling where the plaster was hanging. On 4/5/17 at 4:00 p.m., the surveyor observed the plaster continued to hang from the ceiling. On 4/6/17 at 2:00 p.m., an interview was conducted with EI (Employee Identifier)#7, a maintenance staff member. EI #7 was asked what was hanging from the ceiling in the dining room. EI #7 replied, plaster ceiling flaking. EI #7 was asked why was it hanging. EI #7 replied, moisture being absorbed into the plaster. EI #7 was asked what was the facility's policy on the up keep of the ceiling. EI #7 replied, remove flakes of plaster and patch it. EI #7 was asked when were rounds last made on observing the ceiling. EI #7 replied, daily and a couple times a day. EI #7 was asked what was the potential harm when there was plaster hanging from the ceiling and a resident was sitting under the hanging plaster. EI #7 replied, worst harm would be plaster falling into the food.",2020-09-01
6,COOSA VALLEY HEALTHCARE CENTER,15010,260 WEST WALNUT STREET,SYLACAUGA,AL,35150,2017-04-06,278,D,0,1,0F3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure: 1) Resident Identifier (RI) #2's height was coded on RI #2's 2/25/16, Initial Minimum Data Set (MDS) assessment, 2) RI #4's height and [MEDICAL TREATMENT] status was coded on RI #4's 7/22/16, Significant Change MDS assessment, and 3) RI #5's catheter was coded on RI #5's 10/21/16, Annual MDS assessment. These deficient practices affected RI # 2, RI #4 and RI #5, three of 15 residents whose MDS assessments were reviewed. Findings Include: 1) RI #2 was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #2's Admission Assessment, dated 2/15/16, revealed RI #2 had an admission height of 64 inches. A review of RI #2's Initial MDS assessment with an Assessment Reference Date (ARD) of 2/25/16, revealed RI #2's height was not captured during this assessment period. On 4/6/17 at 1:49 p.m., the surveyor conducted an interview with EI (Employee Identifier) #8, the MDS Coordinator. The surveyor asked EI #8 should there be a weight and height on the MDS. EI #8 replied, Yes. That is asked on all of them. The surveyor asked EI #8 was RI #2's height coded on RI #2's Admission MDS assessment dated [DATE]. EI #8 said RI #2's height was not on the MDS. EI #8 said the area had 0's and she did not know why. The surveyor asked EI #8 should RI #2's height be on the MDS. EI #8 replied, Yes Ma'am. The surveyor asked EI #8 was RI #2's 2/25/16 MDS assessment an accurate assessment. EI #8 said no, it would not be accurate without the height being on it. 2) RI #4 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #4's [MEDICAL TREATMENT]/[MEDICAL CONDITION] care plan, no date, revealed RI #4 started [MEDICAL TREATMENT] 8/2014. A review of RI #4's Significant Change MDS assessment with an ARD of 7/22/16, revealed RI #4's height nor [MEDICAL TREATMENT] status was captured during this assessment period. On 4/6/17 at 1:49 p.m., the surveyor conducted an interview with EI #8. The surveyor asked EI #8 was RI #4's height recorded on RI #4's Significant Change MDS dated [DATE]. EI #8 said no, there were 0's on the MDS. The surveyor asked EI #8 should the height be recorded. EI #8 replied, Yes Ma'am, it should be recorded. The surveyor asked EI #8 was RI #4 on [MEDICAL TREATMENT]. EI #8 said yes. EI #8 said RI #4 had been on [MEDICAL TREATMENT] since 2014. The surveyor asked EI #8 should RI #4, being on [MEDICAL TREATMENT], have captured on the 7/22/16 MDS. EI #8 said yes. The surveyor asked EI #8 did she see where the [MEDICAL TREATMENT] status captured on the MDS. EI #8 said she did not. The surveyor asked EI #8 was this MDS assessment an accurate assessment for RI #4. EI #8 replied, no, not with the [MEDICAL TREATMENT] not being on the MDS. 3) RI #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #5's most recent annual MDS with an ARD of 10/21/2016, revealed RI #5's Foley catheter status was not captured during this assessment period. The Foley was placed on 8/22/16, and should have captured on the 10/21/16 MDS. On 4/16/17 at 4:10 p.m., the surveyor and EI # 8 had a discussion on when RI #5's Foley catheter was placed. It was agreed from reviewing the resident's chart that the catheter was placed on 8/22/16. The MDS dated [DATE] was reviewed. In section H, Bladder & (and) Bowel, Field H0100, [NAME] Indwelling catheter was coded, 0, On 4/16/17 at 4:25 p.m., an interview was conducted with EI #8. EI #8 was asked who was responsible for coding the MDS. EI #8 replied, she was. EI # 8 was asked was RI #5's 10/21/16 MDS coded correctly in regards to the catheter. EI #8 replied, no ma'am. EI # 8 was asked why the catheter was not checked on 10/21/16 in Section H0100. EI #8 replied, an error, an oversight. EI #8 was asked when should it be coded if a person was using a catheter. EI #8 replied, on the assessment that was due. EI #8 was asked why should a catheter be coded if a resident was using a catheter. EI #8 replied, it tells you they have a catheter and it was important to know that. EI #8 was asked why was it important to code correctly on the MDS. EI #8 replied, the MDS gives you a picture of the resident. EI #8 stated when looking at the MDS, you should be able to know everything about the resident.",2020-09-01
7,COOSA VALLEY HEALTHCARE CENTER,15010,260 WEST WALNUT STREET,SYLACAUGA,AL,35150,2017-04-06,279,D,0,1,0F3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to ensure care plans were developed for Oxygen usage for Resident Identifier (RI) #9 and RI #17. This affected two of 15 sampled residents whose plans of care were reviewed. Findings Include: 1) Resident Identifier (RI) #9 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #9's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/5/17 revealed under Section O: Special Treatments, Procedures, and Programs for Respiratory Treatment, RI #9 was using Oxygen during this assessment period. A review of RI #9's (MONTH) physician's orders [REDACTED]. . O2 (oxygen) @ (at) 4L(liter)/min (minute) via (by way of) NC (nasal cannula) A review of RI #9's care plans revealed that RI #9 did not have an Oxygen care plan. On 4/6/17 at 1:49 p.m., the surveyor conducted an interview with Employee Identifier (EI) #8, the MDS Coordinator. The surveyor asked EI #8 was RI #9 using Oxygen. EI #8 said she thought RI #9 was put on Oxygen. The surveyor asked EI #8 if RI #9 had a care plan for the Oxygen usage. EI #8 replied, No Ma'am. The surveyor asked EI #8 should RI #9 have a care plan for the Oxygen usage. EI #8 replied, yes. 2) RI #17 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A Quarterly MDS assessment with an ARD of 2/9/17, revealed RI #17 was receiving Oxygen during this assessment period. On 4/3/17 at 5:22 p.m., during the initial tour of the facility, RI #17 was observed with Oxygen on at 2 Liters per minute by way of a nasal cannula/Concentrator. On 4/4/17 at 4:41 p.m., RI #17 was again observed with the Oxygen on at 2 Liters per minute by way of a nasal cannula/Concentrator. On 4/5/17 at 2:42 p.m., RI #17's Oxygen remained at 2 Liters per minute by way of a nasal cannula/Concentrator. On 4/6/17 at 8:22 a.m., RI #17 was again observed with Oxygen on at 2 Liters per minute by way of a nasal cannula/Concentrator. On 4/6/17 at 1:49 p.m., the surveyor conducted an interview with EI #8. The surveyor asked EI #8 who was responsible for developing care plans. EI #8 said she was. The surveyor asked EI #8 should residents receiving Oxygen, whether routine or as needed (PRN) have a care plan developed for the oxygen usage. EI #8 replied, Yes Ma'am. The surveyor asked EI #8 did RI #17 use Oxygen. EI #8 said RI #17 did. The surveyor asked EI #8, looking at RI #17's care plans, was a care plan developed for the Oxygen usage. EI #8 said RI #17 did not have a care plan for the Oxygen usage. On 4/6/17 at 4:03 p.m., the surveyor conducted an interview with the Director of Nursing, EI #2. The surveyor asked EI #2 should a resident receiving Oxygen have a care plan developed. EI #2 replied, Yes. The surveyor asked EI #2 what was the rationale for having a care plan. EI #2 said to communicate with the staff members the needs of the resident.",2020-09-01
8,COOSA VALLEY HEALTHCARE CENTER,15010,260 WEST WALNUT STREET,SYLACAUGA,AL,35150,2017-04-06,281,D,0,1,0F3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and review of Potter and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure a licensed nurse, Employee Identifier (EI) #9, did not crush Resident Identifier (RI) #16's 9:00 a.m. medications together on 4/22/16. This deficient practice affected RI #16, one of two residents observed for Gastrostomy tube medication administration, and EI #9, one of three medication nurses observed during the medication pass. The facility's RESIDENT CENSUS AND CONDITIONS OF RESIDENTS form, dated 4/3/2017, documented nine residents in the facility with tube feedings. Findings Include: A review of Potter and Perry's FUNDAMENTALS OF NURSING, Ninth Edition, with a copyright date of (YEAR), page 636, Unit V, Foundations for Nursing Practice documented: . 16. b. Do not mix medications together; administer each separately . RI #16 was originally admitted to the facility on [DATE]. The most recent Quarterly Minimum Data Set assessment with an Assessment Reference Date of 2/1/17, assessed RI #16 as having short and long term memory problems with severely impaired cognitive skills for daily decision making. This assessment also indicated RI #16 had a feeding tube during the assessment period. RI #16's (MONTH) (YEAR) physician's orders [REDACTED].#16's PEG (percutaneous gastrostomy) tube at 9:00 a.m. daily. On 4/4/17 at 8:50 a.m., the surveyor observed EI #9 crush all of the above medications together and poured the crushed medications into a medication cup. EI #9 poured 10 cc's (cubic centimeters) of water into RI #16's syringe then poured the crushed medications into the syringe. On 4/6/17 at 1:23 p.m., the surveyor conducted an interview with EI #9. The surveyor read back the observation of the medication pass done for RI #16 on 4/3/17, and asked EI #9 how should crushed medications be prepared. EI #9 replied, Separately. The surveyor asked EI #9 why did she crush RI #16's medications together. EI #9 said it was just her error and her nerves. The surveyor asked EI #9 what was the standard of practice for administering crushed medications. EI #9 said the medications should be administered separately. On 4/6/17 at 4:03 p.m., the surveyor conducted an interview with the Director of Nursing, EI #2. The surveyor asked EI #2 what was the standard of practice for administering crushed medications. EI #2 replied, To crush the medication individually .",2020-09-01
9,COOSA VALLEY HEALTHCARE CENTER,15010,260 WEST WALNUT STREET,SYLACAUGA,AL,35150,2017-04-06,356,C,0,1,0F3P11,"Based on observations, interview and review of a facility policy titled Nursing Staff Posting Sheet, the facility failed to ensure the daily staffing form for the nursing home was documented with the hours worked on the form for four of four days of the survey. This had the potential to affect all 74 residents who reside in the facility. Findings Include: A review of a facility policy titled Nursing Staff Posting Sheet with a revision date of 6/27/2016 revealed the following: POLICY: . Policy Explanation and Compliance Guidelines: 1. The nursing staffing information will contain the following information: . d. The total number and actual hours worked by the following staff: . 2. The facility will post the nurse staffing total number at the beginning of each shift . On 4/3/17 at 4:55 p.m., the staffing form for the nursing home was observed for the day and the evening shift and did not have the hours worked documented on the form. On 4/4/17 at 8:00 a.m., the staffing form for the nursing home was observed for the day shift and did not have the hours worked documented on the form. On 4/4/17 at 4:30 p.m., the staffing form for the nursing home was observed for the evening shift and did not have the hours worked documented on the form. On 4/5/17 at 8:40 a.m., the staffing form for the nursing home was observed for the day shift and did not have the hours worked documented on the form. On 4/5/17 at 3:25 p.m., the staffing form for the nursing home was observed for the evening shift and did not have the hours worked documented on the form. On 4/6/17 at 8:20 a.m., the staffing form for the nursing home was observed for the day shift and did not have the hours worked documented on the form. On 4/6/17 an interview was conducted with Employee Identifier (EI) #1, Clinical Coordinator. EI #1 was asked who was responsible for filling out the daily staffing form. EI #1 replied, she was responsible to fill it out during the week. EI #1 was asked if she filled out the form for all four days of the survey. EI #1 replied, yes. EI #1 was asked what information was required to be documented on the form according to the regulation. EI #1 replied the census, date, number of registered nurses, number of licensed nurses, number of certified nursing assistants, hours worked and the facility name. EI #1 was asked if the staffing forms for 4/3/17, 4/4/17, 4/5/17 and 4/6/17, were documented correctly according to regulation. EI #1 replied no. EI #1 was asked why was it important to have the information documented accurately. EI #1 replied so they (facility) knew how many people were working.",2020-09-01
10,COOSA VALLEY HEALTHCARE CENTER,15010,260 WEST WALNUT STREET,SYLACAUGA,AL,35150,2017-04-06,371,F,0,1,0F3P11,"Based on record reviews, observations, interviews and a review of facility policies titled Food And Supply Storage Procedures, Cleaning and Sanitizing Flatware, Trayline/Taste/Temperature Record, Product Labeling and Dating, and review of a document titled 'Menu Week, the facility failed to ensure: 1. chicken wings, beef burgers and fish patties were sealed in a box in the freezer, 2. chocolate icing in a container in dry storage was sealed, 3. dented cans were not stored with regular cans, 4. a mighty shake in the cooler had not expired, 5. utensils in a canister were not wet and the staff did not wrap the utensil while wet, 6. milk temperatures were taken and recorded on the temperature guide sheet, 7. a jar of jelly was labeled with an open and use by date and stored in the refrigerator, and 8. pimentos in the refrigerator were labeled with an open and use by date. Finding Include 1) A review of a facility policy titled Food and Supply Storage Procedures with a reviewed date of 7/16/16 revealed: POLICY: . Frozen Storage .Wrap food tightly to prevent freezer burn . On 4/3/17 at 4:55 p.m., the surveyor along with the Dietician, Employee Identifier (EI) #3, toured the freezer. The surveyor observed a box of beef burgers, fish patties and chicken wings opened in a box. The plastic in each box was opened and not sealed. On 4/6/17 at 10:00 a.m., the surveyor conducted an interview with EI #3. EI #3 was asked what food items were in the freezer in a box and not sealed. EI #3 replied, chicken wing pieces, fried chicken patties and fish patties. EI #3 was asked who was responsible for making sure food items were sealed after use. EI #3 replied, the staff and maybe the dietary coordinator's job was to go back and check. EI #3 was asked when should food items be sealed. EI #3 replied, soon as possible. EI #3 was asked why were the food items left opened. EI #3 replied, they had a catering job and someone just threw it in there. EI #3 was asked what was the facility's policy on leaving food items opened in the freezer. EI #3 replied, it was supposed to be covered. EI #3 was asked what was the potential harm to the residents when food items were exposed in the freezer and the food was given to the residents. EI #3 replied, food borne pathogen, food borne illness and it affected the quality of food. EI #3 was asked what was on the chicken wings. EI #3 replied, freezer burn. 2) A review of a policy titled Food and Supply Storage Procedures with no date revealed; POLICY: Dry Storage . Store bulk materials in . approved containers that have tight fitting lids . On 4/3/17 at 4:55 p.m., the surveyor, along with the EI #3, observed chocolate fudge icing in dry storage with the left side of the container not sealed properly. On top of the container was a dead spider like bug. On 4/6/17 at 10:07 a.m., an interview was conducted with EI #3. EI #3 was asked what item in the dry storage area was not sealed properly. EI #3 replied, chocolate fudge. EI #3 was asked why was it not sealed properly. EI #3 replied, it was just an accident. EI #3 was asked who was responsible for making sure food items were sealed properly in the dry storage. EI #3 replied, all staff and coordinators were the one to finalize those things. EI #3 was asked what was on top of the container of chocolate icing. EI #3 replied, hair. EI #3 was asked what was the potential harm when items were not sealed properly. EI #3 replied, food borne pathogen, food borne illness and poor quality food. On 4/6/17 at 2:15 p,m., an interview was conducted with EI #4, the Dietary Manager. EI #4 was asked who was responsible for making sure food items were sealed properly in the dry storage area. EI #4 replied, he was. EI #4 was asked what was the facility's policy on sealing food items. EI #4 replied, whatever you use, when you are done with it close it. EI #4 was asked what was the potential harm when items are not sealed properly. EI #4 replied, food can get contaminated and cross contamination. 3) A review of a policy titled Food and Supply Storage Procedures with no date revealed: POLICY: Dry Storage . Remove any dented cans and place in designated dented can area . On 4/3/17 at 4:55 p.m., the surveyor along with the EI #3 observed three cans of carnation vitamin D evaporated milk and one can of pulmo care therapeutic care. The carnation milk was dented at the side and the pulmo care was dented at the top. On 4/6/17 at 10:13 a.m., an interview was conducted with EI #3. EI #3 was asked did she see any dented cans in the dry storage. EI #3 replied, she did. EI #3 was asked why should dented can be placed in a separate location. EI #3 replied, because of food borne pathogen and quality of food. On 4/6/17 at 2:15 p.m., an interview was conducted with EI #4, the dietary manager. EI #4 was asked where were dented cans stored. EI #4 replied, in a section on the kitchen counter. EI #4 was asked who was responsible for removing dented cans from the shelves. EI #4 replied, the sanitation person. EI #4 was asked when should dented cans be removed from the regular cans section. EI #4 replied, they should never be placed on the shelves. EI #4 was asked what was the potential harm when food from dented can were used to serve to the residents. EI #4 replied, contamination and spoilage. 4) A review of a policy titled Food and Supply Storage Procedures with no date revealed: POLICY: Dry Storage . Remove from storage any items for which the expiration date has expired . On 4/3/17 at 4:55 p.m., the surveyor along with EI #3 observed a mighty shake in the cooler with a use by date of (MONTH) 29, (YEAR) on the container. On 4/6/17 at 10:22 a.m., an interview was conducted with EI #3. EI #3 was asked what was the facility's policy on out of date mighty shakes in the cooler. EI #3 replied, if not used by the use by date, throw it out. EI #3 was asked who was responsible for checking the dates on the mighty shakes. EI #3 replied, staff, and the dietary coordinator checked the dates. EI #3 was asked why should expired mighty shakes be removed from the cooler. EI #3 replied, food borne pathogen and poor quality. EI #3 was asked what was the potential harm when expired mighty shakes are given to the residents to consume. EI #3 replied, food borne illness, poor quality and resident dissatisfaction. EI #3 was asked was the observed mighty shake out of date. EI #3 replied, yes. 5) A review of a facility policy titled Cleaning and Sanitizing Flatware with an effective date of 8/1/04 revealed: POLICY: All flatware will be cleaned and sanitized after every use . 5. Allow flatware to air dry . On 4/4/17 at 11:05 a.m., the surveyor observed staff taking silverware out of a canister and wrapping them into napkins. Some of the silverware in the canister was wet. The two staff members were wrapping the wet silverware (spoons and forks) with a napkin. On 4/6/17 at 10:35 a.m., an interview was conducted with EI #5, the dietary coordinator. EI #5 was asked how should utensil be allow to dry. EI #5 replied, we have a fan for them to sit under and air dry. EI #5 was asked what was the facility's policy on drying utensils. EI #5 replied, put them in the green basket and turn them up side down and let them dry. EI #5 was asked who was responsible for making sure utensils were cleaned and air dry properly. EI #5 replied, all staff was responsible. EI #5 was asked should utensil be wrapped wet. EI #5 replied, no ma'am. EI #5 was asked did she wrap the utensils wets. EI #5 replied, yes ma'am. EI #5 was asked why did she wrap wet utensils. EI #5 replied, she was talking and wrapping at the same time. EI #5 was asked what was the potential harm when there was water on utensil and the utensils were in a canister. EI #5 replied, bacteria. 6) A review of a policy titled Trayline/Taste/Temperature Record with an effective date of 8/1/04 revealed: POLICY: Items intended for patient food service are listed on the Patient Tray Service log and temperature record . Menu items: List all items being served for the meal beside the appropriate heading, including Milk, . Record temperature for each item . A review of a document titled Menu Week which used by the cooks, with no effective date, revealed an area for food temperatures to be documented. There was no documentation of milk temperature or no documentation of the milk was written down. On 4/4/17 at 11:05 a.m., the surveyor observed staff taking the temperature of the food. The cook did not take the temperature of the milk nor did she write a milk temperature down. On 4/6/17 at 1:37 p.m., the surveyor conducted an interview with EI #6, the dietary coordinator. EI #6 was asked who was responsible for taking the temperature of the milk and writing it down. EI #6 replied, she was. EI #6 was asked who took the temperature of the milk or wrote it down during the lunch meal on 4/4/17. EI #6 replied, no one. EI #6 was asked what was the facility's policy on taking milk temperatures and writing them down. EI #6 replied, take one milk and take the temperature of it and make sure it was 40 degrees and below and the write the temperature down. EI #6 was asked why was it important to take milk temperatures. EI #6 replied, milk have to be a certain temperature to send to the patient. EI #6 was asked when should you take milk temperature. EI #6 replied, at the beginning of tray line. EI #6 was asked what was the potential harm when temperatures were not taken and milk was given to the residents. EI #6 replied, it could be spoil or hot which cause milk to spoil. EI #6 continue to say it could harm the resident. 7) A review of a policy titled Product Labeling and Dating with an effective date of 8/1/04 revealed: POLICY . PR[NAME]EDURE .Put item name on label . Date received/cooked/opened recorder . Any product without a Discard date tag must be discarded . On 4/3/17 at 4:55 p.m., the surveyor observed a four pound container of grape jelly was opened, sitting on a kitchen shelf with no opened or use-by date on it. On 4/6/17 at 1:30 p.m., an interview was conducted with EI #6, the dietary coordinator. EI #6 was asked what items on the shelf in the kitchen had no open or use-by dates on their containers on Monday (MONTH) 3, (YEAR). EI #6 replied, the jelly. EI #6 was asked who is responsible for labeling containers (items) with open and use-by dates. EI # 6 replied, the salad person normally at that table, plus the dietary coordinator. EI # 6 was asked where should jelly be stored after use. EI # 6 replied, in the refrigerator. EI #6 was asked when should these containers be labeled with open and/or use-by dates. EI #6 replied, food items should be labeled on the day of opening. EI #6 was asked why was it important to have these opened dates and/or use-by dates on the containers. EI #6 replied, in order to know if the food was spoiled and to protect patients from spoiled foods. EI #6 was asked what was the company's policy on labeling items with an opened and/or use-by dates. EI #6 replied, opened then labeled immediately. EI #6 was asked what potential harm could occur from not having open an/or use-by dates on containers of food. EI #6 replied, food could get spoiled or contaminated which could be harmful to residents. 8) A review of a policy titled Product Labeling and Dating with a an effective date of 8/1/04 revealed: POLICY: Product labeling and dating of prepared and processed items. PR[NAME]EDURE: . Any product . must be labeled . Put Item Name on the label . Record date on Discard Date Line . On 4/3/17 at 5:00 p.m., the surveyor observed a medium tray of pimentos in the refrigerator with no open or use by date. On 4/6/17 at 1:47 p.m., the surveyor conducted an interview with EI #6. EI #6 was asked why was there no open or use by date on the pimentos in the refrigerator. EI #6 replied, whoever used it forgot to put the date on it. EI #6 was asked what was the facility's policy on placing a use by date on food items. EI #6 replied, Anything opened you have to label. EI #6 was asked why was there no open date or use by date on the pimentos. EI #6 replied, whoever opened the pimentos did not put a date on them. EI #6 was asked who was responsible for putting a use by date on food items. EI #6 replied, the cook, salad maker or whoever opened the container. EI #6 was asked when should food items be labeled. EI #6 replied, immediately after opening. EI #6 was asked what was the potential harm when residents were served food which did not have an opened or use by date on it. EI #6 replied, you did not know when it was opened, how long it has been there, and you did not want to give the residents spoil foods.",2020-09-01
11,COOSA VALLEY HEALTHCARE CENTER,15010,260 WEST WALNUT STREET,SYLACAUGA,AL,35150,2018-06-07,656,D,0,1,FTJ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure an individualized care plan was developed to address Resident Identifier (RI) #12's use of side rails. This affected one of 16 sampled residents for whom care plans were reviewed. Findings include: RI #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #12's Quarterly Minimum Data Set Assessment, with an Assessment Reference Date of 03/22/2018, indicated RI #12 had short and long term memory impairment and severely impaired cognitive skills for daily decision making. This assessment also documented RI #12 as totally dependent on staff for bed mobility and transfers. RI #12's comprehensive care plans included a care plan for Falls, with a modify date of 01/11/2018. This care plan included an intervention for . 2. SIDE RAILS RAISED x (times) . The care plan did not specify the number or size of siderails to be used. On 6/6/18 at 9:30 AM RI #12 was observed in bed with 1/4 (quarter) side rails up times two. Employee Idenifiter (EI) #3, Registered Nurse (RN), was interviewed on 6/07/18 at 3:43 PM. When asked what purpose RI #12's side rails served, EI #3 said they were for safety. When asked which siderails should be used, EI #3 said the top ones, but was unsure what size rails should be used. EI #3 said the care plan should reflect the size of siderails and which ones to use, but after reviewing RI #12's care plans, said they did not reflect that. EI #4, the Minimum Data Set/ Care Plan Coordinator, was interviewed on 6/07/18 at 4:18 PM. EI #4 said the purpose of a resident's care plans was to ensure you know everything the resident needs, including all care needs. She explained the approaches should reflect the personal choices, likes, dislikes, diagnoses, and care areas for each resident. EI #4 said all care plans should be patient centered. When asked if RI #12's care plans were individualized for the use of side rails, EI #4 said, no not for side rails.",2020-09-01
12,COOSA VALLEY HEALTHCARE CENTER,15010,260 WEST WALNUT STREET,SYLACAUGA,AL,35150,2018-06-07,700,E,0,1,FTJ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure Resident Identifier (RI) #12 was assessed to determine the need for side rails and the risk of entrapment prior to utilizing two upper side rails. Further the facility failed to obtain informed consent prior to applying side rails for RI #12. This affected RI #12 one of one resident sampled for siderail use but had the potential to affect 28 of 64 total residents in the facility identified by staff as using side rails. Findings include: RI #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #12's Quarterly Minimum Data Set Assessment, with an Assessment Reference Date of 03/22/2018, indicated RI #12 had short and long term memory impairment and severely impaired cognitive skills for daily decision making. This assessment also documented RI #12 as totally dependent on staff for bed mobility and transfers. RI #12's comprehensive care plans included a care plan for Falls, with a modify date of 01/11/2018. This care plan included an intervention for . 2. SIDE RAILS RAISED x (times) . The care plan did not specify the number or size of siderails to be used. On 6/6/18 at 9:30 AM RI #12 was observed in bed with 1/4 (quarter) side rails up times two. Employee Idenifiter (EI) #3, Registered Nurse (RN), was interviewed on 6/07/18 at 3:43 PM. When asked what purpose RI #12's side rails served, EI #3 said they were for safety. When asked which siderails should be used, EI #3 said the top ones, but was unsure what size rails should be used. EI #3 said the care plan should reflect the size of siderails and which ones to use, but after reviewing RI #12's care plans, said they did not reflect that. EI #3 also confirmed RI #12 was not able to use the side rails. When asked if she could provide evidence the resident was assessed to determine the risk of entrapment, EI #3 said she could provide a fall risk assessment, but it did not address entrapment, only confusion and falls. When asked if residents should be assessed to determine if side rails were appropriate for them, EI #3 said the facility only used one size of side rail, and it was not individualized for each resident's needs. EI #5, the Interim Director of Nursing, was asked to explain the facility's process for determining whether a resident requires the use of siderails on 6/07/18 3:52 PM . EI #5 said she came to the facility in mid (MONTH) of (YEAR) and had determined the facility was not using an assessment tool for siderails. She also said she was working on a policy, but neither the policy or the assessment for siderails had been implemented yet. When asked how the size of siderail a resident requires should be determined, EI #5 said therapy should be involved in that decision, but that had not yet been implemented. During a follow-up interview with EI #5 on 6/07/18 at 4:55 PM, the Interim Director of Nursing said RI #12 should have two top siderails up, but did not know what size. EI #5 further stated RI #12 had not been assessed for the risk of entrapment; nor did the facility have informed consent for the use of the side rails. On 6/07/18 at 5:18 PM, EI #5 stated the facility did not currently have a policy addressing siderail use. She further said none of the 28 residents identified by the facility as utilizing siderails had informed consent for the use of their side rails.",2020-09-01
13,COOSA VALLEY HEALTHCARE CENTER,15010,260 WEST WALNUT STREET,SYLACAUGA,AL,35150,2018-06-07,812,F,0,1,FTJ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and review of the facility policy titled . SUBJECT: Food and Supply Storage Procedures and review of the (YEAR) Food Code, the facility failed to ensure: 1.) a dented can of pineapple chunks was removed from stock rotation; 2.) Glucerna TF was not stored past the manufacturer's use by date; and 3.) raw chicken was not stored directly over coed/prepared pork tenderloins. These failures had the potential to affect all 60 residents receiving meals from the dietary department. Findings include: Review of the undated facility policy titled . SUBJECT: Food and Supply Storage Procedures revealed the following: . POLICY: Dry Storage * . Remove Dented Cans and place in dented can area for credit and discard. * Remove from storage any items for which the expiration date has expired. * . Store cooked meat above raw meat. On [DATE] at 8:38 AM a can of pineapple chunks was observed on a shelf in the dry storage area in rotation for use. The can had a large dent on the bottom, side of can. The dry storage area also had two cases of expired tube feeding formula (Glucerna 1.2 Cal). The cases had a manufacturer's use by date of [DATE]. On [DATE] at 8:49 AM a rack containing trays of cooked pork tenderloins and raw chicken was observed in the walk-in cooler. The rack had a plastic tray with cooked pork tenderloins, and on each of the three shelves above the cooked pork were sheet pan of raw chicken breasts with blood-colored juices on the pans. Employee Identifier (EI) #1, Dietary staff, confirmed the raw chicken was stored over top of the cooked pork and said raw items should not be stored over cooked items because it could cause contamination.- EI #2, the Dietitian, was interviewed on [DATE] at 8:29 AM. EI #2 said it was important to ensure canned food items did not have dents because of the possibility of the seal being compromised. EI #2 also stated items should be checked on an ongoing basis for use by dates. EI #2 said the Glucerna should not have been stored past the use by date because it exceeded the manufacturer's quality standard. when asked how cooked and raw meat should be stored, EI #2 said raw meat should always be stored on the bottom, with cooked meat above it due to the potential for contamination.",2020-09-01
14,COOSA VALLEY HEALTHCARE CENTER,15010,260 WEST WALNUT STREET,SYLACAUGA,AL,35150,2018-06-07,880,D,0,1,FTJ211,"Based on observations, interviews and review of a facility policy titled, Gloving, the facility failed to ensure a licensed staff member wore gloves when administering a subcutaneous injection to Resident Identifier (RI) #7 on 6/06/2018. This affected one of three residents observed for subcutaneous injections during medication administration observations. Findings include: Review of a facility policy titled: Gloving, with an effective date of 8/2005 revealed: . I. Indications [NAME] To reduce the possibility that personnel will become infected with microorganisms, to reduce the likelihood that personnel will transmit their own endogenous microbial flora to resident . II. [NAME] All employees who come in direct contact with blood or body fluids are to wear gloves . B. Gloves should be worn for any procedure requiring aseptic technique. On 6/06/18 at 4:32 PM, Employee Identifier (EI) #6, Licensed Practical Nurse (LPN), was observed administering a subcutaneous injection to RI #7. EI #6 did not wear any gloves for the administration of the injection. EI #6 was interviewed on 6/07/18 at 3:39 PM. When asked what the facility's policy indicated about when gloves should be worn, EI #6 was unsure; however, after reviewing the policy, EI #6 said gloves should be worn anytime a procedure requires aseptic technique. EI #6 said gloves should be worn when administering a subcutaneous injection to prevent cross contamination.",2020-09-01
15,COOSA VALLEY HEALTHCARE CENTER,15010,260 WEST WALNUT STREET,SYLACAUGA,AL,35150,2019-06-13,880,D,0,1,DC4511,"Based on observations, interviews, and review of the facility's policy titled, PREPARATION AND GENERAL GUIDELINES, the facility failed to ensure: 1) a licensed nurse did not place Resident Identifier (RI) #53's medication on the over bed table, then into her pocket, prior to placing the medication back into the medication cart; and 2) a licensed nurse washed her hands prior to preparing RI #31's medications. These failures affected RI #s 31 and 53, two of five residents, and two of four nurses, observed during medication administration observations. Findings Include: 1) On 6/12/19 at 4:34 p.m., during medication administration observations, Employee Identifier (EI) #3, a Licensed Practical Nurse, removed medication (eye drops) from the medication cart, placed the medication on RI #53's overbed table, then stored the medication in her pocket while administering other medications. EI #3 then returned to the medication cart and placed the eye drops back inside. A phone interview was conducted on 6/13/19 at 11:42 a.m. with EI #3. EI #3 was asked, what should be done before laying medication and supplies on the resident's overbed table. EI #3 stated, Usually it's cleaned off and I put a paper towel there. EI #3 was asked, did you do that yesterday. EI #3 stated, No ma'am. EI #3 was asked, after administering RI #53's eye drops, what did she do with them. EI # 3 stated, I put them in my pocket, then returned them to the med (medication) cart. EI #3 said she was not supposed to store things in her pocket because it could become contaminated. 2) A review of the facility's policy titled, PREPARATION AND GENERAL GUIDELINES, effective (MONTH) (YEAR), revealed: . MEDICATION ADMINISTRATION-GENERAL GUIDELINES Procedures . [NAME] Preparation . 2) Handwashing and Hand Sanitation : The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly: * before beginning a medication pass * prior to handling any medication . On 6/13/19 at 8:23 a.m., EI #4, a Licensed Practical Nurse, left the medication cart and went into the medication room, touching the door handles to the medication room and refrigerator. She then returned to the medication cart and began preparing medications for RI #31 without washing her hands. An interview was conducted on 6/13/19 at 9:10 a.m. with EI #4. EI #4 was asked, before starting to prepare medications, what should be done. EI #4 stated, Wash my hands. EI #4 was asked what she should have done after returning from the medication room, before continuing to prepare RI #31's medications. EI #4 stated, Wash my hands. EI #4 was asked, what is the potential for harm. EI #4 stated, Cross Contamination.",2020-09-01
16,HIGHLANDS HEALTH AND REHAB,15012,380 WOODS COVE ROAD,SCOTTSBORO,AL,35768,2017-03-16,315,D,0,1,WKAI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and a review of a facility policy titled: Hand Hygiene and Incontinent/Perineal Care, the facility failed to ensure incontinent care was provided for RI (Resident Indentifer) #4, a resident with a current Urinary Tract Infection in a manner to prevent cross contamination. On 03/15/17, Employee Identifier (EI) #3/staff Certified Nursing Assistant (CNA), failed to remove soiled gloves and wash her hands when providing incontinent care for RI #4. The CNA repeatedly touched the resident's bottle of peri-wash, the barrier skim cream, the privacy curtain and the residents clean brief while wearing soiled gloves. This affected RI #4, one of one sampled residents observed for incontinent care. Findings Include: A facility policy titled: Hand Hygiene . with an Effective Date: 5/15/2008 .3. Perform hand hygiene: a. before and after having direct contact with patients . A facility policy titled: INCONTINENT/PERINEAL CARE . with a revised date of 2-2016 . PURPOSE: To maintain cleanliness, promote comfort, prevent infection . RI #4 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #4's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/16/17, documented RI #4 as incontinent for bowel and bladder. A facility document titled: .URINALYSIS . with a date of 03/03/17 documented . PROTEIN 2+ H (HIGH) . BLOOD 2+ H . RBC (Red Blood Cells) 11-20 H .WBC ([NAME] Blood Cells) 20-50 H BACTERIA 4+ H . [MEDICATION NAME] DS (Double Strength) one PO (by mouth) BID (twice a day) x (times) 7. Culture. A document titled: MICROBIOLOGY . with a date of 03/06/17 . Urine Culture Final Organism 1. ESCHERICHIA COLI ESBL COLONY COUNT >100,000 colonies/ml (milliters). During an observation of incontinent care for RI #4 on 03/15/17, at 4:25 p.m., EI #3 CNA was observed repeatedly touching RI #4's bottle of peri-wash with the same gloves used to provide the incontinent care. EI #3 failed to remove the soiled gloves and wash her hands before touching RI #4's privacy curtain, placing his/her clean brief on the bed and touched the container of barrier cream. An interview was conducted with EI #3 CNA on 03/16/17, at 11:29 a.m. EI #3 was asked why she repeatedly picked up a bottle of peri-wash with soiled gloves. She stated, No excuse I just was not paying attention. EI #3 was asked what she should have done. She stated, I should have put the peri-wash on the cloths before I started. EI #3 was asked why she failed to remove her soiled gloves and wash her hands before she touched RI #4's clean brief, privacy curtain and barrier cream container. She stated, I knew I messed up after I got done and thought about it. EI #3 was asked what the potential for harm was if soiled gloves were used and hands were not washed before touching a residents clean brief, privacy curtain and barrier cream container. She replied, contamination of perineal area and anything else I touch. EI #3 was asked if RI #4 had a Urinary Tract Infection. She stated, I think she has had one that I know of. An interview was conducted with EI #6 Infection Control Coordinator on 03/16/17, at 9:20 a.m. EI #6 was asked what should a CNA do with soiled gloves before touching a bottle of perineal wash repeatedly, a resident's privacy curtain and clean brief. EI #6 stated, Gloves should be removed.",2020-09-01
17,HIGHLANDS HEALTH AND REHAB,15012,380 WOODS COVE ROAD,SCOTTSBORO,AL,35768,2017-03-16,363,E,0,1,WKAI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and a facility document titled MENU w (with)/DIETS the facility failed to ensure 1/2 cup of the roasted vegetables were served at lunch on 3/15/17, as indicated on the lunch menu. This affected Resident Indentifer (RI) #8, one of eight sampled residents whose meals were observed on 3/15/17 and had the potential to effect 40 of 50 residents receiving meals from the kitchen. Findings Include: Resident Identifier (RI) #8 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a facility document titled MENU w/DIETS for 3/15/17 documented .noon day 18 .ALTERNATE . REGULAR .1/2 c (cup) Roasted Vegetables .MECHANICAL SOFT .Roasted Vegetables . On 3-15-17 at 11:45 a.m., the surveyor observed kitchen staff plating food. When plating the roasted vegetables the staff used kitchen tongs to serve the Roasted Vegetables. On 3-15-17 at 12:11 p.m., during the lunch meal, RI # 8's was served roasted vegetables. On 3-15-17 at 5:00 p.m., an interview was conducted with Employee Identifier (EI) # 8. EI # 8 was asked about the roasted vegetables being served with tongs during lunch on 3-15-17 when the menu called for 1/2 cup. EI #8 replied the staff should have used a scoop or ladle and it couldn't be measured accurately using tongs.",2020-09-01
18,HIGHLANDS HEALTH AND REHAB,15012,380 WOODS COVE ROAD,SCOTTSBORO,AL,35768,2017-03-16,371,F,0,1,WKAI11,"Based on observation, interview and facility policies titled PRODUCTION, PURCHASING, STORAGE, KITCHEN HOOD CLEANING AND MECHANICAL AREA, ROOF AND GROUNDS the facility failed to ensure the following: 1. Boiled eggs were not stored in the refrigerator past the 3 day, use by date. 2. A pan of Jello was not stored past the use by date of 3-12-17. 3. Jello, oranges and pudding were not observed uncovered and undated in the refrigerator. 4. Meat balls, sloppy Joe meat and Corn on the Cobb were not stored in the freezer past the use by date. 5. Roast Beef was not stored in the freezer without a use by date. 6. Diced tomatoes, Swiss cheese and Pepper Jack cheese were not stored in the refrigerator past the use by date. 7. A pipe above the stove was free of a dust like substance. 8. A portion of the ceiling in the kitchen was free of a dark drown substance. This was observed during the initial tour of the facility on 3-14-17 and 3-15-17 and affected 49 of 49 residents receiving meals from the kitchen. Findings Include: A review of a facility policy titled PRODUCTION, PURCHASING, STORAGE with a revised date of 1/16, documented the following: POLICIES: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption . PR[NAME]EDURES; .The words .Use-by should precede the date .foods past the use-by . date should be discarded .Cover, label and date unused portions and open packages .Frozen STORAGE .Food stored frozen should be kept no longer than 3 months for quality purposes .Discard food past the use-by or expiration date . A review of a policy titled KITCHEN HOOD CLEANING effective 1/1/99 documented the following: .Kitchen Hood Cleaning .A licensed service contractor will clean as necessary the kitchen hood system every six (6) months . A review of a facility document check titled MECHANICAL AREA, ROOF AND GROUNDS .CHECKLIST documented the following: .Check the roof monthly, Report any problems . During the initial tour of the kitchen on 3/14/17 from 2:19 p.m. - 3:00 p.m. the following observations were made in the kitchen: 1) Boiled eggs were stored in the refrigerator past 3 days once cooked. 2) Jello was observed with a use by date of 3-12-17 3) Oranges, Pudding and Jello were observed uncovered and undated. 4) Meatballs had a use by date of 3-2-17. 5) Sloppy Joe had a use by date of 3-12-17. 6) Corn on the Cobb had a use by date of 3-7-17. 7) Roast Beef did not have a use by date. 8) Diced tomatoes had a use by date of 3-13-17. 9) Swiss cheese had a use by date of 3-3-17. 10) Pepper Jack cheese had a use by date of 2-21-17. The following observations were made on 3/15/17 from 10:55 a.m. - 11:48 a.m.: 1) Dust accumulations was as on the pipes above the stove. 2) The ceiling in the kitchen was discolored. 3) The Swiss Cheese had a use by date of 3-3-17. 4) Pepper Jack cheese had a use by date of 2-21-17. An interview was conducted with Employee Identifier (EI) #8, Dietitian, on 3/15/17 at 5:00 p.m. EI #8 was asked how long boiled eggs should be kept once cooked. EI #8 replied 3 days and if kept longer there is a potential for food borne illness. EI # 8 was asked if Jello, with a use by date of 3-12-17, was observed on 3-14-17 should it be discarded. EI # 8 replied it should have been discarded. EI # 8 was asked if Jello, Oranges and Pudding should be uncovered and undated. EI #8 replied everything should be covered and have an open and use by date. EI #8 was asked if items in the freezer, such as Meat Balls and Sloppy Joe meat should be kept past the use by date. EI #8 replied no. EI #8 was asked if Roast Beef in the freezer should have a used by date. EI #8 replied yes. EI #8 was asked if items, such as diced tomatoes, Swiss Cheese and Pepper Jack cheese should be kept past the use by date. EI #8 replied no and it could cause food borne illness. EI #8 was asked about dust observed on a pipe above the stove. EI #8 replied there should be no dust near food. EI #8 further stated they have a cleaning schedule for the oven. EI #8 was asked about the stained ceiling in the kitchen. EI #8 replied its been that way a couple of months. EI #8 replied it should be fixed.",2020-09-01
19,HIGHLANDS HEALTH AND REHAB,15012,380 WOODS COVE ROAD,SCOTTSBORO,AL,35768,2017-03-16,425,E,0,1,WKAI11,"Based on a review of a facility documents titled: MEDICATION DESTRUCTION RECORD. and interviews the facility failed to ensure there were three signatures for the drug destruction of Narcotics. This affected six of 12 drug destruction documents reviewed to include March, (YEAR), April, (YEAR) and (MONTH) (YEAR). Findings Include: On 03/16/17, at 8:50 p.m. during a review of facility documents titled: MEDICATION DESTRUCTION RECORD . CONTROLLED SUBSTANCES the surveyor observed 2 signatures for 2 documents dated 03/16/16, 2 documents for (MONTH) (YEAR), one with one signature, and 2 documents dated 01/16/17, with 2 signatures. An interview was conducted on 03/16/17, at 11:00 a.m. with Employee Identifier (EI) #1 Pharmacy Consultant. EI #1 was asked to review the 6 documents for the drug destruction for Narcotics and tell the surveyor how many signatures he observed for the destruction by flushing of Narcotics. EI #1 replied, 5 of the sheets dated 01/16/17 had 2 signatures, (MONTH) (YEAR) had one document with 2 signatures and another with only one signature and 2 documents for (MONTH) (YEAR) had only 2 signatures. EI #1 was asked how many signatures should be on each of the documents. EI #1 replied, 3 signatures. He was asked why there were 2 instead of 3. EI #1 stated, I don't know why. EI #1 was asked what the potential for harm was if 3 people were not present and destroyed Narcotics. He replied, it could be a potential for someone not destroying the medications. Drug diversion possibility. A second interview was conducted on 03/16/17, at 11:15 a.m. with EI #2 Registered Nurse. She was asked to review the 6 documents for the destruction of the Narcotics and tell the surveyor how many signatures she observed. EI #2 replied, 2 documents for (MONTH) 16, (YEAR) had 2 signatures, 2 documents for (MONTH) (YEAR) one included 2 signatures and one document had one signature and 2 documents for (MONTH) (YEAR) had 2 signatures. EI #2 was asked how many signatures should be on the destruction of Narcotics. She stated, 3 Signatures. EI #2 was asked why there were one to 2 signatures on the documents for the drug destruction for Narcotics. She stated, I just can't tell you I have done this for years and haven't ever done this. EI #2 was asked what the potential for harm was if there were one to 2 signatures with the drug destruction of Narcotics. She replied, to be certain they were destroyed.",2020-09-01
20,HIGHLANDS HEALTH AND REHAB,15012,380 WOODS COVE ROAD,SCOTTSBORO,AL,35768,2017-03-16,441,E,0,1,WKAI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and a review of facility policy's titled: Laundry, Hand Hygiene, and Cleaning of Glucose Meter, the facility failed to ensure the following: 1) Clothing items were free of a brown substance after being washed with other resident clothing items. This affected 19 residents receiving laundry services through the facility. 2) Employee Identifier (EI) #3 Certified Nursing Assistant (CNA) removed her soiled gloves and washed her hands while providing incontinent care for Resident Identifier (RI) #4. 3) EI #7 Licensed Practical Nurse (LPN) cleaned the glucometer after checking RI #9's blood sugar. This affected one of one observation of a finger stick during the medication pass on 03/15/17. Findings Include: 1) A review of a facility policy titled, Laundry with a revised date of 05/2011 revealed the following: .Policy: Laundry will be handled in a safe manner .Procedure: .7. The department responsible for ensuring the proper handling . or cleaning of all laundry is Environmental Services. On 03/15/2017 at 9:05 a.m., an observation was made of wet/damp clothing items in a barrel with a pair of black sweat pants with a brown substance. EI #4, Environmental Service Supervisor was asked to observe the clothing item. EI #4 was asked what did the substance look like. EI #4 replied, feces. EI #4 was asked were the clothing inside of the barrel with the black sweat pants already washed. EI #4 replied yes ma'am. EI #4 was asked how were items with visible soiled areas such as feces to be handled in the laundry. EI #4 explained if laundry staff washed items with visible feces they would separate them from other resident clothing items. EI #4 was asked why should visibly soiled clothing items with feces be washed separately from other resident clothing items. EI #4 replied because it would contaminate the rest of the laundry. EI #4 was asked what was the potential harm in washing clothing items with visible substance such as feces with other resident clothing items. EI #4 replied it could cause cross contamination. On 03/16/2017 at 9:20 a.m., an interview was conducted with EI #6, Infection Control Coordinator. EI #6 was asked should a substance identified as bowel movement be observed on an item that has been washed with other clothing items. EI #6 stated,No. 2) A facility policy titled: Hand Hygiene . with an Effective Date: 5/15/2008 .7. Hand hygiene: A general term that applies to any of the following: hand washing, antiseptic hand wash, antiseptic hand rub . B. Indications for hand washing and hand antisepsis . 3. Perform hand hygiene: a. before and after having direct contact with patients . b. after removing gloves . d. after contact with body fluids or excretions, mucous membranes, intact skin, or wound dressings RI #4 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #4's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/16/17, documented RI #4 as incontinent for bowel and bladder. During an observation of incontinent care for RI #4 on 03/15/17, at 4:25 p.m. EI #3 CNA was observed repeatedly touching RI #4's bottle of peri-wash with the same gloves used to provide the incontinent care. EI #3 failed to remove the soiled gloves and wash her hands before touching RI #4's privacy curtain, and placed his/her clean brief on the bed and touched the container of barrier cream. An interview was conducted with EI #3 CNA on 03/16/17, at 11:29 a.m. She was asked what care she provided for RI #4 on 03/15/17 with the surveyors present. EI #3 replied, perineal care. She was asked if RI #4 was incontinent and of what. EI #3 replied, yes ma'am of urine. EI #3 was asked why she repeatedly picked up a bottle of peri-wash with soiled gloves. She stated, No excuse I just was not paying attention. EI #3 was asked what she should have done. She stated, I should have put the peri-wash on the cloths before I started. EI #3 was asked why she failed to remove her soiled gloves and wash her hands before she touched RI #4's clean brief, privacy curtain and barrier cream container. She stated, I knew I messed up after I got done and thought about it. EI #3 was asked what the potential for harm was if soiled gloves were used and hands were not washed before touching a residents clean brief, privacy curtain and barrier cream container. She replied, contamination of the perineal area and anything else I touch. EI #3 was asked if RI #4 had a Urinary Tract Infection. She stated, I think she has had on that I know of. An interview was conducted with EI #5 CNA on 03/16/17, at 11:50 a.m. She was asked what care she had assisted with for RI #4 on 03/15/17 with EI #3. EI #5 replied, perineal care. EI #5 was asked what the potential for harm was if soiled gloves were used to touch clean items during incontinent care. EI #5 stated, Contamination. An interview was conducted with EI #6 Infection Control Coordinator on 03/16/17 at 9:20 a.m. EI #6 was asked what should a CNA do with soiled gloves before touching a bottle of perineal wash repeatedly, a residents privacy curtain and clean brief. EI #6 stated, Gloves should be removed, hand hygiene performed and new gloves put on. EI #6 was asked what infections he was currently monitoring in the facility. He replied, to include UTI (Urinary Tract Infection). 3) A facility policy titled: Cleaning of Glucose Meter . with an effective date of 7/15/14 . POLICY This policy and procedure is to address the cleaning of Glucose Meter . CLEANING PR[NAME]EDURE 1. The meter must be cleaned between patients and prior to docking using approved disinfectant wipe. Resident Identifier (RI) #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #9's (MONTH) (YEAR) Physician order [REDACTED]. An observation of a fingerstick blood sugar check was observed on 03/15/17, at 4:00 p.m. by EI #7 LPN. EI #7 obtained the blood sugar from RI #9 and failed to clean the glucometer before placing it in the top draw of the medication cart. An interview was conducted with EI #7 on 03/15/17, at 6:00 p.m. EI #7 was asked what was the facility's policy related to cleaning the glucometer. EI #7 stated, Clean between each resident. EI #7 was asked why she failed to clean the glucometer after she used it for RI #9. She stated, Nerves. I don't usually work on the cart we had an emergency. EI #7 was asked if she should have cleaned it after obtaining RI #9's blood sugar. She stated, Yes. EI #7 was asked what the potential for harm was if the glucometer was not cleaned after each resident. She stated, Spread of Infection. An interview was conducted with EI #6, Infection Control Coordinator on 03/06/17 at 9:20 a.m. EI #6 was asked what the potential for harm was if the glucometer was not cleaned after using it with a resident. EI # 6 stated, High potential for Hepatitis C, B and blood borne pathogens. EI #6 was asked what should a nurse to do with the glucometer after using it with a resident. EI #6 stated, Wiped down with a peroxide wipe.",2020-09-01
21,HIGHLANDS HEALTH AND REHAB,15012,380 WOODS COVE ROAD,SCOTTSBORO,AL,35768,2018-05-03,550,D,0,1,VXOM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, record review and review of a facility policy titled, Care of Urinary Catheter, the facility failed to ensure Resident Identifier (RI) #29's Foley catheter bag was in a privacy bag and not visible from the hallway on 05/02/18. This deficient practice affected RI #29, one of one resident sampled with a Foley catheter. Findings Include: A review of a facility policy titled, Care of Urinary Catheter, with an effective date of 12/09/04, and a revision date of 1/12, documented: . PR[NAME]EDURE: . 10. Assure the drainage bag is placed in a privacy bag. RI #29 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #29's Foley catheter care plan, with a problem onset date of 03/10/10, documented the following approach: . * privacy bag . A Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 04/09/18, assessed RI #29 as having an indwelling catheter. RI #29's (MONTH) (YEAR) Physician order [REDACTED].> . 16 french 10 cc (cubic centimeter) foley catheter to dependent drainage. Dx. (diagnoses) [MEDICAL CONDITION] bladder s/t (secondary to) spinal cord injury . Privacy bag . On 05/01/18 at 4:15 p.m., RI #29's Foley urinary catheter bag was observed uncovered, attached to the left bed rail, and was visible from the hallway. On 05/01/18 at 5:44 p.m., RI #29's Foley urinary catheter bag remained uncovered and visible to anyone walking past RI #29's room. At this time, the surveyor conducted an interview with Employee Identifier (EI) #3, RI #29's assigned Certified Nursing Assistant (CNA). The surveyor asked EI #3 how should a resident's Foley catheter be when the resident was in bed. EI #3 said the Foley catheter should be attached to the bed frame. When asked should the Foley catheter bag be visible to any one walking past the resident's room, EI #3 said no. EI #3 said the Foley catheter bag should be on the opposite side of the door (bed) or covered. The surveyor asked EI #3 what type of concern/issue would it be considered when a resident's Foley catheter bag was not covered. EI #3 replied, it would be a dignity issue.",2020-09-01
22,HIGHLANDS HEALTH AND REHAB,15012,380 WOODS COVE ROAD,SCOTTSBORO,AL,35768,2018-05-03,812,F,0,1,VXOM11,"Based on observations, interviews, and a review of a facility policy titled, Ice Handling of Ice Scoops and the (YEAR) Food Code U.S. (United States) Public Health Service FDA (Food and Drug Administration), the facility failed to ensure: (1) the ice scoop was not stored on top of the ice machine, on three of four days of the survey; (2) a dark brown colored dust like substance was not on the pipes above the deep fryer, on three of four days of the survey; (3) dust was not on the pipes above the conventional oven, on three of four days of the survey; and (4) the meat slicer did not have food debris on it, on three of fours days of the survey. These deficient practices had the potential to affect all 44 residents receiving meals from the dietary department. Findings Include: (1) A review of an undated facility policy titled, Ice Handling/Cleaning of Ice Scoops, documented: POLICY: . Ice scoops are to be maintained in sanitary conditions in an effort to prevent the spread of infection. PR[NAME]EDURE: . 5. The ice scoop(s) in dietary shall be sanitized each day and placed next to the ice machine in a covered container . On 05/01/18 at 10:21 a.m., the surveyor observed a dietary staff member removing ice from the ice machine. The staff member was using a large blue colored ice scoop. When finished with removing ice from the cooler, the staff member placed the ice scoop on top of the ice machine. The ice scoop was not stored in any type of covering. On 05/02/18 at 8:58 a.m., the surveyor observed the large ice scoop to remain on top of the ice machine, not stored in any type of covering. On 05/03/18 at 8:27 a.m., the large ice scoop was again observed by the surveyor to be laying uncovered on top of the ice machine. On 05/03/18 at 8:28 a.m., the surveyor conducted an interview with Employee Identifier (EI) #6, the Food Service Director. The surveyor asked EI #6 how should the ice scoops be stored. EI #6 said the ice scoop should be stored up out of the bin. The surveyor asked EI #6 should the ice scoop be stored on top of the ice machine. EI #6 said, no. EI #6 said the ice scoop should be stored in a container where it could drain. The surveyor asked EI #6 what was there a potential for when the ice scoop was stored on top of the ice machine, and not in any type of covering. EI #6 replied, contamination. (2) A review of the (YEAR) FOOD CODE U.S. Public Health Service FDA, documented the following: . 4-6 CLEANING OF EQUIPMENT AND UTENSILS . 4-601.11 . Nonfood-Contact Surfaces . (C) NONFOOD-CONTACT SURFACES . shall be kept free of an accumulation of dust . On 05/01/18 at 10:39 a.m., the surveyor observed hanging dust, with a dark brown colored looking substance within the dust, on the pipes above the deep fryer. On 05/02/18 at 9:00 a.m., the hanging dust with the dark brown colored looking substance within the dust remained on the pipes above the deep fryer. On 05/03/18 at 8:22 a.m., the surveyor again observed the hanging dust, with the dark brown colored looking substance within the dust, on the pipes above the deep fryer. On 05/03/18 at 8:23 a.m., the surveyor conducted an interview with EI #6. The surveyor asked EI #6 what did the substance look like on the pipes above the deep fryer. EI #6 said she did not know what the brownish colored substance looked like. The surveyor asked EI #6 how often were the pipes cleaned. EI #6 said she did not know, and maintenance cleaned the pipes. On 05/03/18 at 8:47 a.m., the surveyor conducted an interview with EI #7, the Maintenance man. The surveyor asked EI #7 what did the brownish colored looking particles on the pipes above the deep fryer look like to him. EI #7 replied, greasy dust particles. The surveyor asked EI #7 what was there a potential for if the greasy dust particles came loose. EI #7 said the greasy dust particles could fall into whatever was beneath it. (3) On 05/01/18 at 10:53 a.m., the surveyor observed dust like looking particles on the pipes near the conventional oven as well as near the rice, flour, sugar and meal bins. On 05/02/18 at 9:04 a.m., the dust looking particles remained on the pipes near the conventional oven as well as near the rice, flour, sugar and meal bins. On 05/03/18 at 8:30 a.m., the surveyor again observed the dust like looking particles on the pipes near the conventional oven as well as near the rice, flour, sugar and meal bins. Covered bread sticks and rolls were observed in pans beneath the area where the pipes were. At this time an interview was conducted with EI #6. The surveyor asked EI #6 what was on the pipes. EI #6 said she did not know. When asked how often the pipes were cleaned, EI #6 said maintenance did that. On 05/03/18 at 8:47 a.m., the surveyor conducted an interview with EI #7. The surveyor asked EI #7 what did he see on the pipes above the conventional oven. EI #7 replied, dust. The surveyor asked EI #7 what was there a potential for if the dust would come loose. EI #7 said it could fall into what ever was beneath the pipes. When asked if his department was responsible for keeping the pipes clean, EI #7 said his department had never been given that task. (4) A review of the (YEAR) FOOD CODE U.S. Public Health Service FDA, documented the following: . 4-6 CLEANING OF EQUIPMENT AND UTENSILS . 4-601.11 Equipment, Food-Contact Surfaces . (A) EQUIPMENT FOOD-CONTACT SURFACES . shall be clean to sight and touch . On 05/01/18 at 10:32 a.m., the surveyor observed the meat slicer to have dried food debris on the slicer. On 05/02/18 at 9:02 a.m., the dried food debris remained on the meat slicer. On 05/03/18 at 8:16 a.m., the surveyor again observed the meat slicer to have dried food debris on it. On 05/03/18 at 8:17 a.m., the surveyor conducted an interview with EI #6. The surveyor asked EI #6 what did she see on the meat slicer. EI #6 replied, it kind of looked like meat. The surveyor asked EI #6 how often should the meat slicer be cleaned. EI #6 replied, after each use. When asked when was the meat slicer last used, EI #6 said three days ago. The surveyor asked EI #6 what was there a potential for when food particles were left on the meat slicer. EI #6 said it was a potential for contamination.",2020-09-01
23,HIGHLANDS HEALTH AND REHAB,15012,380 WOODS COVE ROAD,SCOTTSBORO,AL,35768,2018-05-03,814,F,0,1,VXOM11,"Based on observation and interview, the facility failed to ensure the above ground grease receptacle did not have grease and leaves on top of the receptacle, and on the ground in front of the receptacle. This was observed on 04/30/18, during the initial tour of the facility. This has the potential to affect all 45 residents residing at the facility. Findings Include: On 04/30/18 at 4:35 p.m., the surveyor observed the above ground grease receptacle. There were leaves and grease observed on top of the grease receptacle, and on the area on the ground in front of the grease receptacle. At this time, the surveyor conducted an interview with Employee Identifier (EI) #6, the Food Service Director. The surveyor asked EI #6, what did she see on the top of the grease receptacle, and on the ground in front of the grease receptacle. EI #6 said it looked like leaves and grease to her. The surveyor asked EI #6 what was there a potential for when grease and leaves were left on top of the grease receptacle, and on the ground in front of the grease receptacle. EI #6 said the grease and leaves could attract pest.",2020-09-01
24,HIGHLANDS HEALTH AND REHAB,15012,380 WOODS COVE ROAD,SCOTTSBORO,AL,35768,2018-05-03,880,D,0,1,VXOM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, medical record review and review of facility policies titled, Medication Administration and nebulizer use, the facility failed to ensure: 1) licensed staff did not place Resident Identifier (RI) #21's container of eye drops in her pocket after instilling the drops; this was observed on 05/01/18; 2) licensed staff did not place a container of glucometer strips in her pocket, remove them to check a finger stick blood sugar for RI #146, return them to her pocket and place the container on the medication cart; this was observed on 05/01/18; and 3) RI #3's nebulizer mask was stored in a covering on two of four days of the survey. These deficient practices affected RI # 3, one of two residents observed with nebulizer masks, RI #21 one of one resident observed receiving eye drop medication; and RI #146, one of one residents observed receiving nebulizer medication. Findings Include: (1) A review of a facility policy titled Medication Administration, with an updated date of 06/12, revealed: . PR[NAME]EDURE: . 7. Return medication to medication cart and store according to the facility policy. RI #21 was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #21's (MONTH) (YEAR) Physician order [REDACTED].> .1/29/18 ARTIFICIAL TEARS - INSTILL 2 DROPS TO EACH EYE 5 x (times)/DAY . On 05/01/18 at 10:15 a. m., Employee Identifier (EI) #4, Registered Nurse (RN) was observed administering medications to RI #21. EI #4 gave the medications by mouth then placed the eye drop bottle and the breathing treatment vial in her uniform pocket. EI #4 washed her hands, removed the eye drop bottle from her pocket and put on gloves. EI #4 instilled the eye drops then put the eye drop bottle back in her pocket after taking her gloves off. EI #4 washed her hands and removed the breathing treatment medication from her pocket, put on gloves and administered the medication. EI #4 removed her gloves and washed her hands. EI #4 returned to the medication cart and signed the medications off. EI #4 removed the eye drop bottle from her pocket and returned it to the Ziploc bag labeled for the medication and placed it in the medication cart. On 5/02/18 at 2:58 p.m., EI #4 was interviewed. EI #4 was given a recap of the observation on 5/1/18 and then asked if during the medication pass if she instilled eye drops for RI #21. EI #4 replied, yes. EI #4 was asked where should the eye drop container be stored while administering other medications or washing her hands. EI #4 replied, on the table on a barrier. EI #4 was asked what was the policy on storing the eye drop container. EI #4 replied, it should be placed on a barrier on the resident's table while in the room. EI #4 was asked if she put the eye drop container in her uniform pocket. EI #4 replied, yes. EI #4 was asked if the pocket of her uniform would be considered clean or dirty. EI #4 replied, dirty. EI #4 was asked what was the risk of storing the eye drop container in her uniform pocket. EI #4 replied, cross contamination and infection control. On 5/02/18 at 6:10 p.m., an interview was conducted with EI #2, the Director of Nursing (DON). EI #2 was asked what was the policy on where to place an eye drop container after instilling the eye drops. EI #2 replied, on a barrier if in the resident's room, then back on the cart. EI #2 was asked, when should a nurse put an eye drop container in her pocket. EI #2 replied, never. EI #2 was asked if a uniform pocket would be considered clean or dirty. EI #2 replied, dirty. EI #2 was asked what would the risk be in putting the eye drop container back on the medication cart after it was in the uniform pocket. EI #2 replied, the possibility of transferring germs. 2) RI #146 was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. On 5/01/18 at 10:48 a.m., EI #4, a Registered Nurse (RN) was observed obtaining a glucometer check on RI #146. After obtaining the blood sample, EI #4 placed the container of glucometer strips in her uniform pocket and went in to the bathroom to wash her hands. EI #4 returned to the cart cleaned the glucometer, then removed the container of glucometer strips from her pocket and placed it on the medication cart. On 5/2/18 at 5:41 p.m., EI #4 was given a recap of the medication observation on 5/1/18 at 10:48 a.m. and an interview was conducted. EI #4 was asked if she did a glucometer check on RI # 146 before lunch. EI #4 replied, yes. EI #4 was asked what did she do with the container of glucometer strips when she finished. EI #4 replied, she put them in her pocket. EI #4 was asked what was the policy on storing the glucometer strip container. EI #4 replied, on a clean barrier on the resident's table. EI #4 was asked if the pocket of her uniform would be considered a clean area. EI #4 replied, no. EI #4 was asked, why was the pocket of her uniform not considered clean. EI #4 replied, putting your hands in and out would have germs. EI #4 was asked, what would be a risk for storing/placing a glucometer strip container in the pocket of her uniform. EI #4 replied, spreading germs, contamination and infection control issues. On 5/02/18 at 6:10 p.m., an interview was conducted with EI #2, the DON. EI #2 was asked what was the policy on where to place the glucometer strip container when in a resident's room. EI #2 replied, on a barrier on the resident's table. EI #2 was asked when should a nurse put the container of glucometer strips in their pocket. EI #2 replied, never. EI #2 was asked if the pocket of a nurse's uniform would be considered clean or dirty. EI #2 replied, dirty. EI #2 was asked what was the risks of the nurse putting the glucometer strip container in their pocket then returning it to the medication cart. EI #2 replied, possible transferring of germs. (3) RI #3 was admitted to the facility on [DATE], and readmitted on [DATE], with a [DIAGNOSES REDACTED]. A review of a facility policy titled, nebulizer use, with an effective date of 04/17, documented: . PR[NAME]EDURE . 15. Nebulizer compressor and zip lock bag of tubing and accessories to be stored at bedside . RI #3's (MONTH) (YEAR) Physician order [REDACTED].> . IPRAT-ALBUT ([MEDICATION NAME]) 0.5(2.5) MG (milligram)/3ML (milliliter) - ADMINISTER 1 VIAL PER NEBULIZER TID (three times a day) . On 05/02/18 at 8:20 a.m., the surveyor observed RI #3's nebulizer mask hanging from the nebulizer machine. The mask was not in a covering. On 05/02/18 at 3:02 p.m., RI #3's nebulizer mask remained hanging from the nebulizer machine, and not in a covering. On 05/02/18 at 6:17 p.m., the surveyor again observed RI #3's nebulizer mask hanging from the nebulizer machine. The mask remained uncovered. On 05/03/18 at 7:37 a.m., RI #3's nebulizer mask was observed uncovered and continued to hang on the nebulizer machine. On 05/03/18 at 7:43 a.m., the surveyor conducted an interview with Employee Identifier (EI) #8, a Licensed Practical Nurse assigned to care for RI #3. The surveyor asked EI #8 was RI #3 receiving nebulizer treatments. EI #8 said yes. When asked how often RI #3 received the treatments, EI #8 replied, three times a day. The surveyor asked EI #8 how should the nebulizer mask be stored. EI #8 said in a Ziploc bag. The surveyor asked EI #8, when not stored in that manner, what was that a potential for. EI #8 replied, contamination and infection.",2020-09-01
25,HIGHLANDS HEALTH AND REHAB,15012,380 WOODS COVE ROAD,SCOTTSBORO,AL,35768,2019-06-06,812,F,0,1,3PTZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of a facility Policy Titled, Food Storage, the facility failed to ensure that expired food items and undated food items were not present in the food storage area and walk-in cooler during the initial tour of the kitchen. Further, the facility failed to ensure expired Juven was not stored in a cabinet at the nurse's station. This deficient practice had the potential to affect 45 out of 45 residents who received meals from the kitchen. Findings include: Review of a facility policy titled, Food Storage with no date, revealed the following: . 2. Stock is rotated with each delivery to ensure freshness . c.) Stock should be dated . 7. Leftover food . clearly labeled, and dated . On [DATE] at 03:08 PM during the initial tour of the kitchen, observations of the dry storage area revealed the following items: - a container of graham crumbles prepared on [DATE] with a use by date of [DATE] - 1 bag of almonds opened ,[DATE], not labeled with a use by date - 2 out of 4 bags of almonds stamped with a best by date of [DATE] - a bag of macaroni opened and tied closed in a box with no open or use by date noted on the bag or box - one open box of Juven therapeutic nutrition powder with 9 packets inside, as well as 2 full boxes of 30 packets each, all with use by dates of [DATE] - 2 additional closed cases of Juven therapeutic nutrition powder with use by date of [DATE] - eight two-packs of baby food peaches with an expiration date of [DATE], (YEAR) - 3 individual cups of baby food sweet potato with no expiration stamp on the packs - one [MEDICATION NAME] bottle (one liter) for tube feed which had a use before (MONTH) 1, 2019 date stamped on the bottle On [DATE] at 03:39 PM an observation of the walk in freezer revealed frozen sweet peas and frozen breaded cod squares were in an open, clear plastic bag in a box, with no open or use by date noted. On [DATE] at 03:45 PM an observation of the walk in cooler to the right revealed the following items: - a block of cheese opened and rewrapped with use by date of [DATE] and prepared date of [DATE], - opened bag of feta cheese, resealed with a use by date [DATE], prepared on [DATE] - an opened package of provolone sliced cheese, resealed, with a use by date of [DATE] and a prepared date of [DATE]. On [DATE] at 9:35 AM, the surveyor, along with Employee Identifier (EI) #3, Registered Nurse (RN), observed a case of Juven containing three unopened boxes of 30 packets and one opened box containing 17 packets with an expiration date of (MONTH) 2019, in a cabinet at the nurses station. On [DATE] at 05:20 PM an interview with Employee Identifier (EI) #1, Supervisor for Dietary Aides, was conducted. EI #1 was asked to look at the cheese items on the shelf and tell the surveyor if there were any concerns. EI#1 replied, yes, some were expired; they should be thrown out. EI #1 was asked what the potential harm could be in serving food that is expired, and EI #1 replied a person could get food poisoning, or it could make the residents sick. EI #1 was then asked if there should be expired items available to serve to the residents. EI#1 replied, no there should not. EI #1 was asked to look at the [MEDICATION NAME] bottle and if there was a concern. EI#1 replied that it had a date to use before (MONTH) 1, 2019. EI #1 further stated it was expired and should be removed. On [DATE] at 09:32 AM, an interview was conducted with EI #2, the Food Service Director, regarding expired food items. EI #2 was asked, who was responsible for ensuring that expired items are not available. EI #2 answered that all of the supervisors, as well as herself, were responsible. EI #2 was further asked, why there were expired items found in the dry storage and the walk-in coolers. EI#2 replied that they did not do a thorough job in their inspections. EI #2 was then asked, what would be the potential harm in having expired food items available for use. EI #2 answered that the potential harm would be to potentially make someone sick.",2020-09-01
26,HIGHLANDS HEALTH AND REHAB,15012,380 WOODS COVE ROAD,SCOTTSBORO,AL,35768,2019-06-06,880,D,0,1,3PTZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, medical record reviews and review of facility policies titled, Universal Precautions and Hand Hygiene, the facility failed to ensure: 1) a licensed nurse washed her hands when removing gloves after obtaining Resident Identifier (RI) # 9's fingerstick blood sugar (FSBS) and before leaving RI #9's room to return to the medication cart. Further, the nurse failed to use a barrier when laying an insulin syringe with RI #9's insulin and alcohol wipe on the bathroom sink; and 2) a licensed nurse did not place a medication cup containing medication for RI #23 inside another medication cup containing the remainder of RI #23's medication. Further, the nurse did not use a barrier before placing RI #23's Salonpas patches and [MEDICATION NAME] on the top of the medication cart, computer and a shelf in RI #23's room. These deficient practices affected RI #9 and RI #23, two of four residents and two of three nurses observed during medication pass observations. Findings Include: 1) A review of a facility policy titled, Hand Hygiene, Last Revised: 02/2019, documented: .B. Indications for hand washing and hand antisepsis .3. Perform hand hygiene: a. before and after having direct contact with patients; b. after removing gloves; before handling an invasive device (regardless of whether or not gloves are used) for patient care; .f. after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; . A review of a facility policy titled, Universal Precautions, Last Revised: 02/2019, revealed: .[NAME] Hand Washing .3. Hands should be sanitized immediately after gloves are removed. B. 1. Gloves should be worn for touching blood and body fluids, . 1.) RI #9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 06/05/19 at 5:04 p.m., the surveyor observed Employee Identifier (EI) #7, Registered Nurse (RN), during medication pass for RI #9. The surveyor observed EI #7, RN, obtain RI #9's FSBS and remove her gloves without washing her hands and returned to the medication cart to prepare RI #9's insulin injection. EI #7 was then observed entering RI #9's bathroom and laying the syringe filled with insulin and the alcohol wipes beside the bathroom sink without a barrier. On 06/05/19 at 5:17 p.m., an interview was conducted with EI #7, RN. EI #7 was asked when should she wash her hands when wearing gloves. EI #7 said she should wash them when she takes them off. EI #7 was asked did she wash her hands after obtaining RI #9's FSBS and removing her gloves before returning to the medication cart. EI #7 stated no. EI #7 was asked what should she do before laying anything down on any surface. EI #7 replied she should put down a barrier. EI #7 was asked did she put down a barrier before she laid the insulin syringe and alcohol wipe beside the sink. EI #7 stated no she did not. EI #7 was asked what was the concern with laying things down on surfaces without a barrier. EI #7 answered, it could be dirty and there could be germs. 2.) RI #23 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 06/06/19 at 8:39 a.m., EI #3, RN, was observed during medication pass for RI #23. EI #3 was observed removing two of RI #23's Salonpas patches from the packet and laying them on top of the medication cart without a barrier to initial and date them. EI #3 removed the nitro dur patch from the packet and laid it on top of the computer on the medication cart to initial and date it. EI #3 was then observed placing a medication cup containing [MEDICATION NAME] and placing it inside another medication cup containing the remainder of RI #23's pills. EI #3 entered RI #23's room and placed the items on a shelf unit inside the room without placing a barrier. On 06/06/19 at 9:21 a.m., an interview was conducted with EI #3, RN. EI #3 was asked what was the concern with placing a medication cup inside another medication cup containing medications. EI #3 said dirty stuff could be on them, infection control. EI #3 was asked what was the concern with placing Salonpas and nitro patches on the computer and on top of the medication cart to date them. EI #3 replied again, getting them dirty. EI #3 was asked did she place the Salonpas and nitro patch on her computer, top of the medication cart and on the shelving unit in RI #23's room without a barrier. EI #3 said yes. On 06/06/19 at 3:47 p.m., an interview was conducted with EI #5, RN/Director of Nursing. EI #5 was asked, when should nurses wash their hands when wearing gloves. EI #5 said as soon as the gloves come off the hands should be washed. EI #5 was asked should a medication cup containing medications be placed inside another medication cup containing medications. EI #5 replied no. EI #5 was asked should patches be placed on a shelving unit without a barrier. EI #5 stated no. EI #5 was asked what was the concern with those things. EI #5 answered infection control and cross contamination.",2020-09-01
27,EASTVIEW REHABILITATION & HEALTHCARE CENTER,15014,7755 FOURTH AVENUE SOUTH,BIRMINGHAM,AL,35206,2019-01-24,812,F,0,1,TMYV11,"Based on observations, interviews, and review of facility policies titled, SANITARY CONDITIONS OF THE FOOD SERVICE DEPARTMENT, and, FOOD FROM OUTSIDE SOURCES, the facility failed to ensure: 1. vents located above the tray line were clean and not full of dust particles; and 2. foods being brought in from outside the facility were properly labeled and were discarded after expiration. These failures had the potential to effect 62 of 74 residents in the facility, who received meals from the kitchen. Findings include: 1. A facility policy titled, SANITARY CONDITIONS OF THE FOOD SERVICE DEPARTMENT revised 2/15, revealed, POLICY: Facilities and equipment used in the preparation and serving of food provided to residents are safe and sanitary. PR[NAME]EDURE: 1. The facility is arranged so contact with contaminated sources . is unlikely to occur. On 01/23/19 at 11:33 a.m. , while watching the tray line, a large vent above where the tray line was being conducted, was observed to be full of gray dust-like particles. On 01/24/19 at 09:52 a.m. an interview was conducted with Employee identifier (EI) #3, Dietary Manager. EI #3 was asked, who is responsible for cleaning the vents in the kitchen. EI #3 replied, maintenance does it. EI #3 was asked, how often are they cleaned. EI #3 replied, he cleans them, usually once a month. EI #3 was asked if she noticed a lot of dust in the vent located above the tray line yesterday. EI #3 replied, yes. EI #3 was asked, what is the potential concern for a vent, located above where the tray line is, being full of dust. EI #3 replied, particles could get in the food. 2. A facility policy titled, FOOD FROM OUTSIDE SOURCES, revised 10/17, revealed, POLICY: The facility procures food based on the current menu from sources approved or considered satisfactory by federal, state or local authorities. Food that is brought to residents from family, visitors or volunteers is handled in a safe and sanitary manner. PR[NAME]EDURE: . 4. a. ii. Refrigerated foods are labeled with the date and time of storage. iii. Commercially prepared foods are discarded no later that the Use By Date. b. iii. The label includes the resident's name and room number, the date it is received and stored, and the date it should be discarded. A tour of the refrigerator on unit two with EI #5, Certified Nursing Assistant, on 01/23/19 at 4:48 p.m. revealed, a brown plastic bag with a resident's name on the outside and nothing else, contained an open container of potato salad with an expiration date of 1/14/19. An interview was conducted with EI #4, Licensed Practical Nurse, on 01/24/19 at 10:19 a.m EI #4 was asked, who is responsible for checking the dates of food items in the unit refrigerators. EI #4 replied, house keeping normally does that. EI #4 was asked, how should food items brought in from outside the facility be stored. EI #4 replied, it is supposed to have the name and date, and be separately bagged. EI #4 was asked, when should food items be is discarded. EI #4 replied, definitely after food expires or spoils. EI #4 was asked, what is the potential concern of an out-dated item being in the unit refrigerator. EI #4 replied, a resident could get sick.",2020-09-01
28,EASTVIEW REHABILITATION & HEALTHCARE CENTER,15014,7755 FOURTH AVENUE SOUTH,BIRMINGHAM,AL,35206,2019-01-24,880,D,0,1,TMYV11,"Based on observation, interviews, and review of a facility policy titled, Standard Precautions, the facility failed to ensure a Laundry Aide did not allow clean towels, sheets, and wash cloths touch her dress on her upper body when removing these items from the second dryer and during folding. Further, the Laundry Aide did not wash her hands after putting soiled laundry in the small washing machine, prior to putting on another pair of gloves. This had the potential to affect 23 of 74 residents in the facility. Findings Include: A review of a facility policy titled, Standard Precautions, with a revised date of 12/2009, revealed: .1. Hand Hygiene a. Wash hands after touching .contaminated items, whether or not gloves or worn . On 01/24/19 at 08:43 a.m., the surveyor observed the laundry room in the facility. The surveyor observed Employee Identifier (EI) #1, a Laundry Aide, remove the following clean items (for station 1 residents) from the second dryer: 4 sheets and 4 pads. The items touched her personal dress on the upper body area. The surveyor observed EI #1 fold the 4 sheets and 4 pads and touched her personal dress on her upper body area. On 01/24/19 at 08:53 a.m., the surveyor observed EI #1 put on a disposable apron and gloves. EI #1 removed the soiled towels, wash cloths, and sheets from the gray linen container for station 1 residents. EI#1 placed the soiled items in the small washing machine, started the washing machine to wash the clothes, removed her gloves (EI #1 did not wash hands), put on gloves, and rolled the gray linen container to the outside of the soiled utility room. An interview was conducted on 01/24/19 at 11:23 a.m. with EI #1, a Laundry Aide. EI #1 was asked when you took the 4 sheets and 4 pads from the second dryer for station 1 residents and started folding these items, did the clean laundry items touch your dress on your upper body. EI#1 stated she did not intend for the clothes to touch her dress, but should have put on an apron. EI #1 was asked if clean clothes being removed from a dryer and folding clean laundry should touch an employee's dress. EI #1 stated no, because it could contaminate the clean clothing and a resident has a potential to get an infection. EI #1 was asked what did you do after you removed the soiled towels, wash cloths and sheets from the gray linen container for station 1 residents, and placed these items in the small washer. EI #1 stated she removed her gloves, and did not wash her hands, put on another pair of gloves, and then rolled the gray linen cart to outside of soiled utility room. EI#1 was asked why did you not wash your hands after putting the soiled linen for station 1 residents in the small washer. EI #1 stated that she should have, but didn't. EI #1 was asked what was the concern with not washing your hands after placing soiled laundry in the washer. EI #1 stated you can spread germs to other people. EI #1 was asked what the facility policy was on hand hygiene. EI #1 stated you should pull your gloves off after touching a contaminated item and wash your hands. EI #1 was asked if the facility policy was followed. EI #1 stated no. On 01/24/19 at 11:45 a.m. an interview was conducted with EI #2, Housekeeping/Laundry Supervisor. EI #2 was asked what was the concern with a laundry aide taking 4 sheets and 4 pads from the second dryer, touching her personal dress with these items, and then touching her personal dress when folding these items. EI #2 stated it could cause contamination and infection to anyone. EI #2 was asked what was the concern when a laundry aide removed soiled towels, wash cloths and sheets from a gray linen container, placed these soiled items in the small washing machine, and not wash her hands prior to putting on another pair of gloves, and then roll the gray linen container to outside of the soiled utility room. EI #2 stated it could cause contamination and infection to other residents. EI #2 was asked what was the facility policy on handling of soiled laundry with hand hygiene. EI #2 stated you should wash your hands after touching anything that is contaminated and this prevents the spread of infection.",2020-09-01
29,EASTVIEW REHABILITATION & HEALTHCARE CENTER,15014,7755 FOURTH AVENUE SOUTH,BIRMINGHAM,AL,35206,2018-01-25,636,D,0,1,I9JH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview with staff and review of a facility policy titled ADMINISTRATIVE POLICY, the facility failed to ensure Resident Identifier (RI) #285's fall risk assessment was completed upon admission. This deficient practice affected one of one residents investigated for falls. Findings Include: A review of a facility policy titled, ADMINISTRATIVE POLICY with a revised date of 10/2013 documented the following: . PURPOSE: Residents are assessed, . to identify care needs and to develop a plan of care. STANDARD: According to federal regulations, the facility conducts initially . a comprehensive, accurate . assessment of each resident's functional capacity . RI #285 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #285's 14 day assessment Minimum Data Set (MDS) with an Assessment Reference Date of 12/28/2017 revealed RI #285's Brief Interview for Mental Status score of 7, indicating cognition was severely impaired. Section G of the MDS, documented RI #285 required two plus person physical assist with transfers. On 01/24/18 at 6:00 PM, RI #285 told the surveyor he/she had a fall on 01/19/2018 when going to the bathroom with one staff member assisting him/her. RI #285 said he/she hurt his right side and hit his/her upper right forehead. He/she said he/she had pain to the right side of his/her abdominal area. RI #285 said an X-ray was done. RI #285 said he/she had tennis shoes on and the nurse took him/her by wheelchair into the bathroom and when he/she was trying to get back into the wheelchair from the toilet he/she fell . RI #285 said he/she was told there were no fractures. RI #285 said usually with his/her transfers that there is always two staff members, but this time there was only one staff member. On 01/25/2018 at 08:30 AM, RI #285's fall risk assessment dated [DATE] was reviewed on the computer and observed to be blank. The surveyor asked for a copy of the fall risk assessment. Employee Identifier (EI) #1, Registered Nurse (RN) Director of Nursing (DON) and EI #2, RN, MDS Coordinator provided a filled out/completed fall risk assessment hand signed and dated 01/25/2018 (no time was documented). On 01/25/2018 at 9:15 AM, EI #2 was asked when was the fall risk assessment filled out. EI #2 said she had filled it out on 01/25/2018 at 9:00 AM. EI #2 was asked if the fall risk assessment had been completed on admission. EI #2 said, no and this was the first fall risk assessment done on RI #285. EI #2 was asked if the fall assessment was completed in the computer, why was it not signed in the computer. EI #2 said because she wanted to talk to the person who initially did the assessment. EI #2 was asked why was the fall assessment hand signed by herself and EI #1. EI #2 said, because it was never done initially. EI #2 was asked who was responsible to complete the . Fall Risk Assessment. EI #2 said, the admitting nurse.",2020-09-01
30,EASTVIEW REHABILITATION & HEALTHCARE CENTER,15014,7755 FOURTH AVENUE SOUTH,BIRMINGHAM,AL,35206,2018-01-25,656,D,0,1,I9JH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and a review of a facility policy titled Care Plans the facility failed to ensure a care plan was developed for fall prevention on resident identifier (RI) #285. This deficient practice affected one of 18 sampled residents whose Care Plans (CP) were reviewed. Findings Include: A review of a facility policy titled Care Plans with a revised date of 09/2009 documented the following: . PURPOSE: Plans of Care are developed by the interdisciplinary team, to coordinate and communicate the plan of care for the resident. STANDARD: According to federal regulations, the facility develops a comprehensive plan of care for each resident . to meet a resident's medical, nursing and mental/psychosocial needs . PR[NAME]ESS: I. Entry Record a) . assessment must be completed on every admission . no later that the entry date Plus 14 calendar days . II. a) The comprehensive assessment is completed no later that 14 days of admission . RI #285 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #285's 14 day assessment Minimum Data Set (MDS) with an Assessment Reference Date of 12/28/2017 revealed RI #285's Brief Interview for Mental Status score of 7, indicating cognition was severely impaired. Section G of the MDS, documented RI #285 required two plus person physical assist with transfers. On 01/24/18 at 06:00 PM, RI #285 told the surveyor he/she had a fall on 01/19/18 when going to the bathroom with one staff member assisting him/her. RI #285 said he/she hurt his right side and hit his/her upper right forehead. He/she said he/she had pain to the right side of his/her abdominal area. RI #285 said an X-ray was done. RI #285 said he/she had tennis shoes on and the nurse took him/her by wheelchair into the bathroom and when trying to get back into the wheelchair from the toilet he/she fell . RI #285 said he/she was told there were no fractures. RI #285 said usually with his/her transfers there was always two staff members, but this time there was only one staff member. On 01/25/2018 at 8:30 AM, RI #285's Fall Risk assessment dated [DATE] was reviewed on the computer and it was observed to be blank. The surveyor asked for a copy of the Fall Risk Assessment. Employee Identifier (EI) #1, Registered Nurse (RN) Director of Nursing (DON) and EI #2, RN, MDS Coordinator provided a filled out/completed Fall Risk Assessment which was hand signed and dated 01/25/2018 (no time was documented). RI #285's care plan (CP) was reviewed and no fall CP was found. On 01/25/2018 at 9:15 AM, EI #2 was asked when was the Fall Risk Assessment filled out. EI #2 said at 9:00 a.m., on 01/25/2018 and she had filled it out. EI #2 was asked if the Fall Risk Assessment had been completed on admission. EI #2 said, no and this was the first Fall Risk Assessment done on RI #285. EI #2 was asked if completed in the computer why was it not signed in the computer. EI #2 said because she wanted to talk to the person who initially did the assessment. EI #2 was asked why was it hand signed by herself and EI #1. EI #2 said because it was never done initially. EI #2 was asked who was responsible to fill the Fall Risk Assessment out. EI #2 said, the admitting nurse. EI #2 was asked if RI #285 had ever had any falls at the facility. EI #2 said, yes sometime last week with no injury. EI #2 was asked how did RI #285 fall. EI #2 said she did not know. EI #2 was asked what interventions were in place for falls upon admission. EI #2 said, she did not know. EI #2 was asked if there was a fall CP for RI #285. EI #2 said, no. RI #285's 12/28/17 MDS documented RI #285 required two person assist with transfers. EI #2 was asked did the MDS address if RI #285 was at risk for falls. EI#2 said, no it did not. EI #2 was asked was fall CP put in place after RI #285 fell on [DATE]. EI #2 said, no. EI #2 was asked should RI #285 been CP for falls. EI #2 said, yes.",2020-09-01
31,EASTVIEW REHABILITATION & HEALTHCARE CENTER,15014,7755 FOURTH AVENUE SOUTH,BIRMINGHAM,AL,35206,2018-01-25,676,D,0,1,I9JH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, medical record review, and a review of Fundamentals of Nursing Chapter 28 the facility failed to ensure palm guards were applied to Resident Identifier (RI) #32's hands as directed by physician's orders [REDACTED].#32 with a call bell he/she could activate if assistance is needed. These deficient practices affected one of one residents sampled for rehabilitation and restorative. Findings Include: A review of Potter and Perry Fundamentals of Nursing with a copyright of (YEAR) Chapter 28 Immobility, page 408 and 414 documented: . Nurses intervene to maintain maximum Range of Motion (ROM) in unaffected joints and . collaborate with physical therapists to design interventions to strengthen affected muscles, and joints . Fingers and Thumb. The ROM in the fingers and thumb enables a patient to perform Activities of Daily Living (ADLs) and activities requiring fine-motor skills . Resident Identifier (RI) #32 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #32's annual Minimum Data Set (MDS) with an Assessment Reference Date of 01/01/2018 revealed RI #32's Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section G of the MDS, for Functional Status documented RI #32 was totally dependent on staff for all activities of daily living (ADL) and Range of Motion (ROM) upper extremity impairment on both sides. A review of RI #32's (MONTH) (YEAR) Physician order [REDACTED]. On 01/24/18 at 10:05 AM, RI #32's call button was secured to the gown. RI #32 was asked if he/she could push the call button. RI #32 attempted to push the call button but could not due to bilateral contractures to hands. RI #32 was observed not having palm guards in his/her hands. On 01/24/18 at 12:30 PM, RI #32 was observed not having palm guards in his/her hands. On 01/25/18 03:30 PM, the surveyor and Employee Identifier (EI) #3 Registered Nurse (RN) Unit Manager to RI #32's room assess hands. EI #3 attempted to open the fingers on bilateral hands with no success. EI #3 was asked if there were palm guards in RI #32's hands bilaterally. EI #3 said no. On 01/25/18 at 02:56 PM, an interview was conducted with EI #3, Registered Nurse/Unit Manager. EI #3 was asked what did the (MONTH) Physician order [REDACTED]. EI #3 said to have the palm guards to bilateral hands. EI #3 was asked why should RI #32 have the palm guards. EI #3 said for contracture management. EI #3 was asked who was responsible to ensure RI #32 had the palm guards per Physician order. EI #3 said the nurse. EI #3 was asked if the Physician order [REDACTED].#3 said no. On 01/25/18 at 03:00 PM, EI #3 to RI #32's room with the surveyor. EI #3 asked RI #32 to push the call button. RI #32 was unable to push the call button due to hands being contracted. EI #3 was asked how did RI #32 make the staff aware when he/she needed something. EI #3 said RI #32 would call out or the roommate would let someone know. EI #3 said she should have gotten RI #32 another type of call button that he/ she could use. EI #3 was asked why could RI #32 not push the call button. EI #3 said because of the hand contractures. EI #3 asked what was the potential harm in RI #32 not being able to push the call button. EI #3 said it puts RI #32 at risk for aspiration and danger.",2020-09-01
32,EASTVIEW REHABILITATION & HEALTHCARE CENTER,15014,7755 FOURTH AVENUE SOUTH,BIRMINGHAM,AL,35206,2018-01-25,684,D,0,1,I9JH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, resident record review, review of a facility policy titled Monthly Physician's Orders and review of a facility policy titled Pressure Ulcers the facility failed to ensure licensed staff provided as needed (PRN) Medication as ordered for constipation for Resident Identifier (RI) #77 and further failed to ensure RI #32 was turned and repositioned every two hours as care planned. These deficient practices affected two of 18 residents sampled. Findings include: 1. Review of the facility policy titled Monthly Physician's Orders with an effective date of 2/1/2004 revealed the following: . PURPOSE: To provide a documented review of the medical plan of care for each resident on a monthly basis by the physician. Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #77's Admission MDS (Minimum Data Set) assessment with an Assessment Reference Date of 12/26/17 revealed a BIMS (Brief Interview for Mental Status) score of 13 which indicated intact cognition. On 01/24/18 at 04:13 PM RI #77 told the surveyor about having to take stool softeners at times because of constipation. RI #77 said, I ask for them about every three days. On 01/25/18 at 05:26 PM RI #77 told the surveyor about having gone three, maybe four consecutive days without having a bowel movement (BM). RI #77 said, About one time a week they have to pull it (BM) out. RI #77's (MONTH) (YEAR) Physicians orders documented: . Order Date . 12/19/17 . [MEDICATION NAME] SODIUM 100 MG (milligram) SOFTGEL- GIVE ONE SOFTGEL BY MOUTH DAILY AS NEEDED FOR CONSTIPATION . 12/19/17 POLYETHYLENE [MEDICATION NAME] 3350 POWD- (powder) GIVE 17GM (gram) BY MOUTH DAILY AS NEEDED FOR CONSTIPATION . Review of RI #77's (MONTH) (YEAR) Bowel Report and DAILY BM (Bowel Movement) MONITORING SHEET revealed four consecutive days Resident #77 did not have a Bowel Movement, 1/12/18, 1/13/18, 1/14/18, and 1/15/18. Review of RI #77's (MONTH) (YEAR) Medication Administration Record [REDACTED]. On 01/25/18 at 5:55 PM, Employee identifier (EI) #4, Certified Nursing Assistant (CNA) said she took care of the resident about three days a week on first shift. When asked about RI #77's bowel patterns, EI #4 said, RI #77 did not really have BMs on the first shift. EI #4 was asked how often RI #77 was constipated. EI #4 was not sure but said, RI #77 might have BMs on another shift. On 01/25/18 at 6:25 PM, EI #5, CNA said, she always took care of RI #77 when she worked on the second shift. When asked what RI #77's bowel patterns were, EI #5 said, RI #77 did not really have a BM and sometimes nurses had to give a stool softener. EI #5 said, RI #77 would sometimes ask the staff to dig the BM out because it was stuck in RI #77's bottom. On 01/26/18 at 9:45 AM, EI #3, Registered Nurse (RN) was asked how many days had RI #77 gone without having a BM. EI #3 said, she was not sure, but the resident would be treated with standing orders or with a laxative already in place, if they did not have a BM in three days. When asked how often RI #77 had to be cleaned out (have BM manually removed), EI #3 said, maybe once or twice. On 01/26/18 at 11:30 AM, EI #1, Director of Nursing (DON) was asked how she would know when residents were not having regular BMs. EI #1 said, the facility had a system in their computerized charting called the BM report and it reported residents who had not had a BM for three days. EI #1 was asked to review both the Bowel Report and the BM Monitoring Sheets and was asked how many days Resident #77 had gone without a BM. After reviewing the reports EI #1 said, four days (1/12, 1/13, 1/14, and 1/15). When asked what she would expect staff to do if RI #77 was requesting BM to be pulled out and had BM stuck inside the rectum, EI #1 said, call the Doctor, treat, and assess. 2. A review of a facility policy titled Pressure Ulcers with a revised date of 11/2011 documented: . STANDARD: Pressure Ulcers are defined as ulcerations and/or necrosis of tissues overlying a bony prominence that has been subjected to pressure . PRESSURE ULCER PREVENTION . Assist the resident to change position . every two hours . Resident Identifier (RI) #32 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #32's annual Minimum Data Set (MDS) with an Assessment Reference Date of 01/01/2018 revealed RI #32's Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. Section G of the MDS, for Functional Status documented RI #32 was totally dependent on staff for all activities of daily living (ADL). Section M documented RI #32 was at risk of developing pressure ulcers. On 01/24/2018 at 10:01 AM, RI #32 was observed lying in supine position. On 01/24/18 at 12:30 PM, RI #32 was observed lying in supine position. On 01/24/2018 at 03:00 PM, RI #32 was observed lying in supine position. On 01/25/18 at 03:00 PM, an interview with Employee Identifier (EI) #3, Registered Nurse (RN) Unit Manager. EI #3 was asked did RI #32 have any pressure ulcers. EI #32 said, no. EI #3 was asked if RI #32 was at risk for developing pressure ulcers. EI #32 said, yes. EI #3 was asked how often was RI #32 to be turned. EI #3 said, every two hours because RI #32 is at risk for developing pressure ulcers. EI #3 was asked who was responsible to ensure RI #32 was turned. EI #3 said, the Certified Nursing Assistants (CNA) and the nurses. EI #3 was asked if RI #32 could turn or reposition his/her self. EI #3 said, no. EI #3 was asked what was the potential harm in not turning RI #32 every two hours. EI #3 said, potential for developing pressure ulcers.",2020-09-01
33,EASTVIEW REHABILITATION & HEALTHCARE CENTER,15014,7755 FOURTH AVENUE SOUTH,BIRMINGHAM,AL,35206,2018-01-25,688,D,0,1,I9JH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of Physician order's, review of Fundamentals of Nursing and staff interview the facility failed to ensure Resident Identifier (RI) #32's hand splints were in place to prevent decreased ROM. This deficient practice was observed on three of four days of the survey for one of one residents sampled for rehabilitation and restorative. Findings Include: A review of Potter and Perry Fundamentals of Nursing with a copyright of (YEAR) Chapter 28 Immobility page 408 and 414 documented: . Nurses intervene to maintain maximum Range of Motion (ROM) in unaffected joints and . collaborate with physical therapists to design interventions to strengthen affected muscles and joints . Fingers and Thumb. The ROM in the fingers and thumb enables a patient to perform Activities of Daily Living (ADLs) and activities requiring fine-motor skills . Resident Identifier (RI) #32 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #32's annual Minimum Data Set (MDS) with an Assessment Reference Date of 01/01/2018 revealed RI #32's Brief Interview for Mental Status (BIMS) score of 15, indicating intact. cognition. Section G of the MDS, for Functional Status documented RI #32 was totally dependent on staff for all activities of daily living (ADL) and Range of Motion (ROM) upper extremity impairment on both sides. A review of RI #32's (MONTH) (YEAR) Physician order [REDACTED]. On 01/24/2018 at 10:05 AM, RI #32's call button was observed secured to his/her gown. RI #32 was asked if he/she could push the call button. RI #32 responded he/she could not push the call button and he/she did not know he/she had one. RI #32 attempted to push the call button but could not due to bilateral contractures to hands. Bilateral hands observed with no palm guards. On 01/24/2018 at 12:30 PM, RI #32 was observed without palm guards in bilateral hands. On 01/25/2018 03:30 PM, the surveyor and Employee Identifier (EI) #3 Registered Nurse (RN)/Unit Manager went to RI #32's room assess hands. EI #3 attempted to open the fingers on bilateral hands with no success. EI #3 was asked if there were palm guards in RI #32's hands bilaterally. EI #32 said, no. On 01/25/2018 at 02:56 PM, an interview was conducted with EI #32. EI #32 was asked what did the (MONTH) Physician order [REDACTED]. EI #3 said, to have the palm guards to bilateral hands. EI #3 was asked why should RI #32 have the palm guards. EI #3 said, for contracture management. EI #3 was asked who was responsible to ensure RI #32 had the palm guards per Physician order. EI #3 said, the nurse. EI #3 was asked if the Physician order [REDACTED].#3 said, no. On 01/25/2018 at 03:00 PM, EI #3 went to RI #32's room with the surveyor. EI #3 asked RI #32 to push the call button. RI #32 was unable to push the call button due to hands being contracted. EI #3 was asked how did RI #32 make the staff aware when he/she needed something. EI #3 said, RI #32 would call out or the roommate would let someone know. EI #3 said, I should have gotten RI #32 another type of call button that he/she could use. EI #3 was asked why could RI #32 not push the call button. EI #3 said, because of the hand contractures. EI #3 asked what was the potential harm in RI #32 not being able to push the call button. EI #3 said, puts RI #32 at risk for aspiration and danger. Position, Mobility 01/24/2018 10:01 AM, RI #32' bilateral hands observed with fingers clinched and closed. RI #32 was asked to open his/her hands and said, I can not open them. A review of RI #32's (MONTH) (YEAR) Physician orders [REDACTED]. RI #32 was observed lying supine with no palm guards on to bilateral hands. 01/24/2018 12:30 PM, resident observed in supine position. 01/24/2018 03:00 PM, resident observed in same supine position. 01/25/18 14 03:00 PM, an interview was conducted with EI #3, RN/Unit Manager. EI #3 was asked did RI #32 have any pressure ulcers. EI #3 said, No. EI #3 was asked if RI #32 was at risk for developing pressure ulcers. EI #3 said, yes. EI #3 was asked how often was RI #32 to be turned. EI #3 said, every two hours because RI #32 was at risk for pressure ulcers. EI #3 was asked who was responsible to ensure RI #32 was turned. EI #3 said, the CNA and nurses. EI #3 was asked could RI #32 turn or reposition his/herself. EI #3 said, no. EI #3 was asked what is the potential harm in not turning and repositioning RI #32. EI #3 said, the potential for developing a pressure ulcer.",2020-09-01
34,EASTVIEW REHABILITATION & HEALTHCARE CENTER,15014,7755 FOURTH AVENUE SOUTH,BIRMINGHAM,AL,35206,2018-01-25,689,D,0,1,I9JH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, a review of a facility policy titled Resident Assessment Instrument the facility failed to ensure a resident admitted to the facility was assessed for falls and a fall prevention care plan was in place prior to the resident sustaining a fall on 12/20/17. This deficient practice affected Resident Identifier (RI) #285, one of one sampled resident investigated for falls. Findings Include: A review of a facility policy titled Resident Assessment Instrument with a revised date of 10/2013 documented . PURPOSE: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop a plan of care. STANDARD: According to federal regulations, the facility conducts initially . a comprehensive, accurate . assessment of each resident's functional capacity . RI #285 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #285's 14 day assessment Minimum Data Set (MDS) with an Assessment Reference Date of 12/28/2017 revealed RI #285's Brief Interview for Mental Status score of 7, indicating severely impaired cognition. Section G of the MDS, documented RI #285 required two plus person physical assist with transfers. On 01/24/2018 at 06:00 PM, RI #285 told the surveyor he/she had a fall on 01/19/18 when going to the bathroom with one staff member assisting him/her. RI #285 said he/she hurt his right side and hit his/her upper right forehead. He/she said he/she had pain to the right side of his/her abdominal area. RI #285 said an X-ray was done. RI #285 said he/she had tennis shoes on and the nurse took him/her by wheelchair into the bathroom and when trying to get back into the wheelchair from the toilet he/she fell . RI #285 said he/she was told there were no fractures. RI #285 said usually with his/her transfers there was always two staff members, but this time there was only one staff member. On 01/25/2018 at 08:30 AM, RI #285's Fall Risk assessment dated [DATE] was reviewed on the computer and it was observed to be blank. The surveyor asked for a copy of the Fall Risk Assessment. Employee Identifier (EI) #1, Registered Nurse (RN) Director of Nursing (DON) and EI #2, RN, MDS Coordinator provided a filled out/completed Fall Risk Assessment which was hand signed and dated 01/25/2018 (no time was documented). On 01/25/2018 at 9:15 AM, EI #2 was asked when was the Fall Risk Assessment filled out. EI #2 said at 9:00 a.m., on 01/25/2018 and she had filled it out. EI #2 was asked if the Fall Risk Assessment had been completed on admission. EI #2 said, no and this was the first Fall Risk Assessment done on RI #285. EI #2 was asked if completed in the computer why was it not signed in the computer. EI #2 said because she wanted to talk to the person who initially did the assessment. EI #2 was asked why was it hand signed by herself and EI #1. EI #2 said because it was never done initially. EI #2 was asked who was responsible to fill the Fall Risk Assessment out. EI #2 said, the admitting nurse. EI #2 was asked if RI #285 had ever had any falls at the facility. EI #2 said, yes sometime last week with no injury. EI #2 was asked how did RI #285 fall. EI #2 said she did not know. EI #2 was asked what interventions were in place for falls upon admission. EI #2 said, she did not know. EI #2 was asked if there was a risk for falls care plan (CP) for RI #285. EI #2 said, no. EI #2 was asked what would have indicated to her that RI #285 needed a fall CP. EI #2 said, the fall risk assessment. EI #2 was asked how would she have known if RI #285 needed a fall CP if the fall assessment was not done. EI #2 said, we missed out on this one. The 12/28/2017 MDS RI #285 was a two person assist with transfers does the MDS address if RI #285 was at risk or not for falls. EI#2 said no it does not. EI #2 was asked was a fall CP put in place after the fall on 01/20/2018. EI #2 said no. EI #2 was asked should have RI #285 been CP for falls. EI #2 said, yes.",2020-09-01
35,EASTVIEW REHABILITATION & HEALTHCARE CENTER,15014,7755 FOURTH AVENUE SOUTH,BIRMINGHAM,AL,35206,2020-02-20,880,D,0,1,C4NW11,"Based on observation, interviews, record review, and review of a facility policy titled Standard Precautions, the facility failed to ensure a Licensed Nurse washed her hands after she administered an eye drop medication to Resident Identifier (RI) #24, removed her gloves, and prior to administering RI #24's oral medications. This affected one of three nurses and one of three residents observed during medication pass. Findings Include: A review of a facility policy titled Standard Precautions, with a revised date of 9/2010, revealed . Standard Precautions will be used in the care of all residents . POLICY INTERPRETATION AND IMPLEMENTATION: 1. Hand Hygiene. b. Wash hands immediately after gloves are removed. and when otherwise indicated to avoid transfer of microorganisms to other residents or environments. On 2/20/20 at 8:30 a.m., the surveyor observed Employee Identifier (EI) #1, a Registered Nurse (RN), during medication administration pass. EI #1 gave an eye drop medication to RI #24's right and left eyes, removed her gloves, and did not wash her hands or use hand sanitizer prior to administering RI #24's oral medications. On 2/20/20 at 10:30 a.m., the surveyor conducted an interview with EI #1. EI #1 was asked, what she should have done after administering an eye drop medication to RI #24, removing her gloves, and prior to administering RI #24's oral medications. EI #1 stated she should have removed her gloves and washed her hands. EI #1 was asked why she had not wash her hands or used hand sanitizer. EI #1 stated, she forgot. EI #1 was asked, what does the facility Hand Washing Policy state should be done after giving a resident an eye drop medication and removing gloves. EI #1 stated, go directly and wash hands. EI #1 stated, hands should be washed before patient care, after patient care, after removing gloves, before applying gloves and in between residents. EI #1 was asked, what would be the concern if a Licensed Nurse did not wash or sanitize her hands after she gave an eye drop medication, removed her gloves, and prior to administering oral medications. EI #1 stated, it could transfer germs to the resident, herself, or other people. On 2/20/20 at 10:45 a.m., the surveyor conducted an interview with EI #2, an Infection Control Preventionist/Registered Nurse. EI #2 was asked, what should a Licensed Nurse do after she gave an eye drop medication, removed her gloves, and prior to administering oral medications. EI #2 stated, she should wash her hands or use a hand sanitizer. EI #2 was asked, what does the facility Hand Washing Policy state should be done after administering an eye drop medication to a resident, removing gloves and prior to administering an oral medication to a resident. EI #2 stated, she should wash her hands after she removed her gloves. EI #2 was asked, what would be the concern if a Licensed Nurse did not wash her hands or use hand sanitizer after she gave an eye drop medication, removed her gloves, and prior to administering oral medications. EI #2 stated, it could cause an infection to the resident, the nurse, and other people.",2020-09-01
36,PLANTATION MANOR NURSING HOME,15015,6450 OLD TUSCALOOSA HIGHWAY   P O BOX 97,MC CALLA,AL,35111,2017-03-09,225,E,0,1,VTS511,"Based on interview, review of employee files, and the facility policy titled Policy and Procedure Abuse, Neglect, Exploitation And Reporting Abuse, the facility failed to ensure all employees considered for potential hire were screened to include reference checks before being allowed to work in the facility. This affected three of six employee files reviewed. This deficient practice had the potential to affect all 88 residents residing in the facility. The RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) dated 3/6/2017 indicated the facility had a total of 88 residents. Findings include: Review of the facility policy titled Policy and Procedure Abuse, Neglect, Exploitation And Reporting Abuse, with a revised date of 12/1/2016 revealed the following: .Compliance Guidelines: .3. Screening-Facility will screen potential employees for a history of abuse, neglect or mistreating residents. This includes attempting to obtain information from previous employers . d. Background, reference . check should be conducted on employees prior to or at the time of employment, . EI (Employee Identifier) #1 LPN (Licensed Practical Nurse), was hired at the facility on 10/12/2016. EI #2 CNA (Certified Nursing Assistant) was hired at the facility on 10/21/2016. A review of EI #1 and #2's employee files revealed there was not any documentation that references had been checked or investigated. On 3/8/2017 at 3:40 p.m. EI #4, ADON (Assistant Director of Nursing), responsible for reference checks on nursing staff, was asked about the facility policy for checking references prior to hire. EI #4 said, all employees should have a reference check prior to being hired. When asked about documentation of reference checks for EI #1 and #2, EI #4 said, she usually documented beside the reference listed on the application, but she failed to document those. When asked where she documented the date and time of the reference check, EI #4 replied, she did not document the date and time, and only documented the reference check was okay. When asked why it was important to perform reference checks before hire of potential employees, EI #4 said, she may learn something about a potential employee that may be beneficial to the facility. EI #3, a House Keeper was hired at the facility on 10/31/2016. Review of EI #3's file revealed there was not any documentation that references had been checked or investigated. On 3/8/2017 at 4:00 p.m. EI #5, Environmental Service Manager, was asked who verified employee screening was completed prior to hire. EI #5 replied, the company contracted for house keeping employees sends the completed screening to him. When asked why EI #3's reference checks were not done before EI #3 started to work, EI #5 said, he did not notice the reference checks were not done.",2020-09-01
37,PLANTATION MANOR NURSING HOME,15015,6450 OLD TUSCALOOSA HIGHWAY   P O BOX 97,MC CALLA,AL,35111,2017-03-09,226,E,0,1,VTS511,"Based on interview, review of employee files, and the facility policy titled Policy and Procedure Abuse, Neglect, Exploitation And Reporting Abuse, the facility failed to ensure the abuse policy was fully implemented for the element of Screening, to include reference checks of all potential employees prior to hire. Three of six employee files reviewed did not include reference checks. This deficient practice had the potential to affect all 88 residents residing in the facility. The RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) dated 3/6/2017 indicated the facility had a total of 88 residents. Findings include: Review of the facility policy titled Policy and Procedure Abuse, Neglect, Exploitation And Reporting Abuse, with a revised date of 12/1/2016 revealed the following: .Compliance Guidelines: . 3. Screening-Facility will screen potential employees for a history of abuse, neglect or mistreating residents. This includes attempting to obtain information from previous employers and/or current employers, .d. reference .check should be conducted on employees prior to or at the time of employment, . EI (Employee Identifier) #1 LPN (Licensed Practical Nurse), was hired at the facility on 10/12/2016. EI #2 CNA (Certified Nursing Assistant) was hired at the facility on 10/21/2016. A review of EI #1 and #2's employee files revealed there was not any documentation that references had been checked or investigated. On 3/8/2017 at 3:40 p.m. EI #4, ADON (Assistant Director of Nursing), responsible for reference checks on nursing staff, was asked about the facility policy for checking references prior to hire. EI #4 said, all employees should have a reference check prior to being hired. When asked where the documentation of reference checks was for EI #1 and #2, EI #4 said, she usually documented beside the reference listed on the application, but she failed to document those. EI #3, a House Keeper was hired at the facility on 10/31/2016. Review of EI #3's file revealed there was not any documentation that references had been checked or investigated. On 3/8/2017 at 4:00 p.m. EI #5, Environmental Service Manager, was asked who verified employee screening was completed prior to hire. EI #5 replied, the company contracted for house keeping employees sends the completed screening to him. When asked why EI #3's reference checks were not done before EI #3 started to work, EI #5 said, he did not notice the reference checks were not done. On 3/8/2017 at 6:00 p.m., EI #6 Abuse Coordinator, was asked what steps were taken to screen potential employee hires for a history of reported abuse. EI #6 said, reference checks were included in the screening. When asked why potential employees were hired prior to reference checks, EI #6 replied, I don't know. When asked who was responsible to ensure the abuse policy was followed, EI #6 stated, I am responsible. EI #6 said, it was important to check all potential hires references to make sure references were accurate and employees were truthful about their past employment experience.",2020-09-01
38,PLANTATION MANOR NURSING HOME,15015,6450 OLD TUSCALOOSA HIGHWAY   P O BOX 97,MC CALLA,AL,35111,2018-04-19,577,C,0,1,K9LV11,"Based on observations, interview, and a review of a facility policy titled, MEGA RULE REVIEW TOOL, the facility failed to ensure postings for the local and state ombudsman included an electronic mailing address. This was observed on one of three survey days and had the potential to affect all ninety-eight residents that reside in the facility. Findings Include: A review of an undated facility document titled, MEGA RULE REVIEW TOOL, revealed: . Resident Rights . Furnish a list of names, addresses (mailing and email), and telephone numbers of all pertinent State regulatory and information agencies, resident advocacy groups . the State Long-Term Care Ombudsman program . An observation was made on 4/17/18 at 2:57 PM of the Ombudsman poster in the main lobby and on the east wing. The posters did not have the Ombudsman's email address listed. An observation was made on 4/17/18 at 5:15 PM of three posters with the Ombudsman's information. The Ombudsman's email address was not listed in the information. An interview was conducted with EI (Employee Identifier) #3, the Social Services designee, on 4/19/18 at 12:34 PM. EI #3 was asked who was responsible for ensuring contact information posted in the facility was complete and she answered, Me. EI #3 was asked what postings should be available to the residents and visitors. EI #3 answered, We have to have the local and state ombudsman, the elder abuse neglect exploitation hotline, and complaint hotline. EI #3 was asked what should those postings include. EI #3 answered, Name, address, email address, and phone number. EI #3 was asked had all of those requirements been included on the posters in the facility during the survey. EI #3 answered, Not the email address. EI #3 was asked what was the concern of posted contact information not including an email address. EI #3 answered, If they couldn't reach them on the phone, they may be able to reach them via email.",2020-09-01
39,PLANTATION MANOR NURSING HOME,15015,6450 OLD TUSCALOOSA HIGHWAY   P O BOX 97,MC CALLA,AL,35111,2018-04-19,641,D,0,1,K9LV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an interview, a review of the medical record, and a review of a facility policy titled, Conducting an Accurate Resident Assessment, the facility failed to ensure side rails were coded accurately on RI (Resident Identifier) #45's Quarterly MDS (Minimum Data Set) dated 3/2/18. This affected RI #45, one of twenty-three residents whose MDS assessments were reviewed. Findings Include: A review of an undated facility policy titled, Conducting an Accurate Resident Assessment, revealed: Policy: The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. Accuracy of Assessments means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial status . Policy Explanation and Compliance Guidelines: . 7. A registered nurse will sign and certify that the assessment/correction request is completed. Each individual who completes a portion of the assessment will sign and certify the accuracy of that portion of the assessment. A review of the medical record for RI #45 revealed a re-admission date of [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS dated [DATE] revealed RI #45 used bed rails as a restraint daily. A review of a physician's orders [REDACTED]. 1/2 (half) side rail in place for T&P (Turning and Positioning) . A review of RI #45's care plan, with a next review date of 6/8/18, revealed: Problem/Need . REQUIRES limited to Total ASSISTANCE WITH ADLs (Activities of Daily Living) . Approaches . siderails in place for safety & (and) T&P . An interview was conducted with EI (Employee Identifier) #4, the LPN (Licensed Practical Nurse)/MDS Coordinator, on 4/19/18 at 3:54 PM. EI #4 was asked who was responsible for ensuring restraints were coded correctly. EI #4 answered, Me. EI #4 was asked why did RI #45 use bed rails. EI #4 answered for turning and positioning and also related to a history of [MEDICAL CONDITION]. EI #4 was asked what did the care plan indicate the rails were used for and she replied for turning, re-positioning, and safety. EI #4 was asked if the rails were coded correctly on the Quarterly MDS and she answered no. EI #4 was asked why not. EI #4 answered because they were not used as a restraint. EI #4 was asked what was the facility's policy regarding accuracy of assessments. EI #4 answered everything should be checked for accuracy before the assessment was submitted. EI #4 was asked what was the concern of an assessment being coded incorrectly. EI #4 answered the care plan might not be accurate.",2020-09-01
40,PLANTATION MANOR NURSING HOME,15015,6450 OLD TUSCALOOSA HIGHWAY   P O BOX 97,MC CALLA,AL,35111,2018-04-19,700,D,0,1,K9LV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interviews, and a review of a facility policy titled, BED RAILS, the facility failed to ensure a bed rail assessment was completed prior to use of bed rails for RI (Resident Identifier) #45. This affected RI #45, one of three residents sampled for bed rail use. Findings Include: A review of an undated facility policy titled, BED RAILS revealed: Policy: The facility must ensure that residents treatment and care in accordance with professional standards if (of) practice, the comprehensive person-centered care plan, and the resident's choices. Policy Explanation and Compliance Guidelines: . 2. If a bed or side rail is used, the facility must ensure correct installation, use and maintenance of bed rails, including but not limited to the following elements: a. Assess the resident for risk of entrapment from bed rails prior to installation. 7. The facility will conduct ongoing assessments to evaluate risks and assure the bed rails is used to meet the residents' needs. A review of the medical record for RI #45 revealed a re-admission date of [DATE], with [DIAGNOSES REDACTED]. A review of the Quarterly MDS dated [DATE], revealed RI #45 used bed rails as a restraint daily. A review of a physician's orders [REDACTED]. 1/2 (half) side rail in place for T&P (Turning and Positioning) . A review of RI #45's care plan, with a next review date of 6/8/18, revealed: Problem/Need . REQUIRES limited to Total ASSISTANCE WITH ADLs (Activities of Daily Living) . Approaches . siderails in place for safety & (and) T&P . A review of the medical record revealed no bed rail assessment was completed for RI #45. An interview was conducted with EI (Employee Identifier) #1, a LPN (Licensed Practical Nurse), on 4/19/18 at 12:26 PM. EI #1 was asked who was responsible for ensuring bed rail assessments were completed. EI #1 answered that he did them when residents were admitted to the facility. EI #1 was asked who was responsible for the assessment after admission. EI #1 answered staff would let him know and he would do it. EI #1 was asked if he was notified of the new rails for RI #45. EI #1 answered no and added he knew changes were made to the mattress and that was what he did. EI #1 was asked when should assessments be done for bed rail use and he answered as soon as bed rails were ordered. EI #1 was asked why should bed rail assessments be completed. EI #1 answered for safety and ongoing assessments to see if the resident's immobility had increased. EI #1 was asked what was the concern of not assessing a resident prior to use of bed rails. EI #1 answered the resident may not get the needed assistance from them. An interview was conducted with EI #5, the Director of Nursing, on 4/19/18 at 4:19 PM. EI #5 was asked who was responsible for ensuring bed rail assessments were completed. EI #5 answered EI #1. EI #5 was asked who was responsible for bed rail assessments after admission and she responded EI #1. EI #5 was asked if EI #1 was notified of the new bed rails for RI #45 and she answered yes. EI #5 was asked when should the assessments be completed for bed rail use. EI #5 answered when use began and per manufacturer's guidelines. EI #5 was asked why should bed rail assessments be completed. EI #5 answered to make sure residents do not become entrapped or restrained. EI #5 was asked what was the concern of not assessing a resident prior to the use of bed rails. EI #5 answered to make sure staff were doing what was appropriate for the resident.",2020-09-01
41,PLANTATION MANOR NURSING HOME,15015,6450 OLD TUSCALOOSA HIGHWAY   P O BOX 97,MC CALLA,AL,35111,2018-04-19,730,C,0,1,K9LV11,"Based on record reviews, an interview, and a review of a facility policy titled, IN-SERVICE TRAINING POLICY, the facility failed to ensure evidence could be provided for four CNAs (Certified Nursing Assistants) receiving 12 hours of mandatory annual training. This was observed in four of four CNA training records reviewed. Findings Include: A review of an undated facility policy titled, IN-SERVICE TRAINING POLICY, revealed: Employees will receive training (in-service) according to (Name of Facility) INCs (Incorporation's) requirements, and state and federal requirements. Procedure . D The facility will provide at least 12 hours of in-service training annually to include dementia & (and) abuse training. A review of inservice sign-in sheets provided to the surveyor revealed four CNAs names had been highlighted. However, there were no documented start/end times or number of hours for the in-services that were provided. There was no evidence of how many in-service hours the CNA's had obtained. An interview was conducted with EI (Employee Identifier) #7, the ADON (Assistant Director of Nursing), on 4/19/18 at 1:16 PM. EI #7 was asked who was responsible for ensuring CNAs received 12 hours of continuing education each year. EI #7 answered, I am. EI #7 was asked who was responsible for ensuring CNAs received training to include abuse and dementia care and she stated she was responsible. EI #7 was asked had CNAs received training to include abuse and dementia care and she answered, Yes. EI #7 was asked if she could provide evidence of the number of hours of training the CNAs had received and she answered, No. EI #7 was asked what was the facility's policy regarding annual training for CNAs. EI #7 answered, That they should receive 12 hours of inservice training per calendar year. EI #7 was asked what was the concern of not being able to verify CNAs had received 12 hours of training. EI #7 answered, I would not be able to prove that they got the training.",2020-09-01
42,PLANTATION MANOR NURSING HOME,15015,6450 OLD TUSCALOOSA HIGHWAY   P O BOX 97,MC CALLA,AL,35111,2018-04-19,732,C,0,1,K9LV11,"Based on observations, an interview, and a review of a facility policy titled, Nurse Staffing Posting Information the facility failed to ensure staffing hours were posted for shifts worked on two of three survey days. This had the potential to affect all ninety-eight residents residing in the facility. Findings Include: A review of a facility policy titled, Nurse Staffing Posting, with a copyright date of (YEAR), revealed: . Policy: It is the policy of this facility to make staffing information readily available in a readable format to resident and visitors at any given time. Policy Explanation and Compliance Guidelines: 1. The nurse staffing information will be posted on a daily basis and will contain the following information: . d. The total number and the actual hours worked by the following categories of licensed and unlicensed staff directly responsible for resident care per shift: i. Registered Nurses ii. Licensed Practical Nurses/Licensed Vocational Nurses iii. Certified Nurse Aides. An observation was made on 4/17/18 at 2:57 PM of a dry erase board at the center nurse's station. The following shifts were identified: 10:30 PM-7:00 AM; 6:30 AM-3:00 PM; and 2:30 PM-11:00 PM. The names of staff were on the board according to the shifts to be worked, but there were no hours posted for the 10:30 PM-7:00 AM shift. An observation was made on 4/17/18 at 4:52 PM of the dry erase board. The posting of hours worked for 10:30 PM-7:00 AM and 6:30 AM-3:00 PM shifts was not completed. An observation was made on 4/18/18 at 11:46 AM of the board where staffing was to be posted. There were no hours documented as worked on the board for the 10:30 PM-7:00 AM shift at that time. An observation was made on 4/18/18 at 4:48 PM of the staff posting board. There were no entries for hours worked for any of these shifts: 10:30 PM-7:00 AM, 6:30 AM-3:00 PM, and 2:30 PM-11:00 PM shifts. An interview was conducted on 4/18/18 at 4:57 PM with EI (Employee Identifier) #7, the ADON (Assistant Director of Nursing). EI #7 was asked who was responsible for posting the staffing hours. EI #7 reported she was responsible. EI #7 was asked where in the building were staffing hours posted. EI #7 answered at the front desk (center station) on the left wall. The surveyor and ADON observed the board at the front desk. EI #7 was asked if anything (hours) had been posted the past two days and she answered no. EI #7 was asked should the hours have been posted and she answered yes, after each shift. EI #7 was asked why and she answered so people would know how many actual hours were worked.",2020-09-01
43,PLANTATION MANOR NURSING HOME,15015,6450 OLD TUSCALOOSA HIGHWAY   P O BOX 97,MC CALLA,AL,35111,2018-04-19,812,F,0,1,K9LV11,"Based on observations, interviews, and a review of the facility's policy and procedure titled, HANDWASHING the facility failed to ensure EI (Employee Identifier) #9, a dietary worker, performed hand washing when going from the dirty dish washing area to the clean dish washing area and when storing clean dishes after working in the dirty dish area. This was observed on one of three survey days and had the potential to affect all ninety-seven residents receiving meals from the kitchen. Findings Include: A review of an undated facility policy titled, HANDWASHING revealed: Policy: Staff will wash hands as frequently as needed throughout the day following proper hand washing procedures . 1. When to Wash Hands: . After handling soiled equipment or utensils. After engaging in other activities that contaminate the hands. On 04/18/18 at 03:00 PM, an observation of the dish washing process was made. EI #9 entered into the dish washing area. EI #9 was observed to place dirty dishes into the dish rack, then placed the dirty dishes into the dish washer and without washing his hands pulled clean dishes out of dish washer. EI #9 continued to load dirty dishes into the dish racks and move to the clean dish area and pick up clean dishes and took them to the storage area in the kitchen. EI #9 was never observed washing his hands in between movement from dirty to clean areas. EI #9 left the washing area and on return, stopped and tied his shoe, then continued into the clean dish area and never washed his hands. An interview was conducted with dietary worker, EI #9 on 04/18/18 at 4:38 PM. EI #9 was asked what was the facility policy for dish washing. EI #9 replied the dirty dishes had to be run through the dish washer and the clean dishes could not be put back with the dirty dishes because that was cross contamination. EI #9 also said he had to wash his hands when he touched the dirty dishes before he could touch the clean dishes. EI #9 was asked if he had followed the facility policy while washing dishes that day. EI #9 replied, no he did not. EI #9 also said he kept forgetting to wash his hands. EI #9 was informed of the observation made of him entering the dish washing area, placing dirty dishes in the washing racks, placing them into the dish washer, then going into the clean dish area and putting away clean dishes. EI #9 was asked if that was what he did. EI #9 replied yes that was what he did. EI #9 said he forgot to wash his hands. An interview was conducted with the Dietary Manager, EI #8 on 4/19/18 at 6:49 PM. EI #8 was asked what was observed on 4/18/18, during dish washing, after the lunch meal and before the dinner meal was served. EI #8 said the wash aide, EI #9, crossed over from the dirty dish washing side to the clean dish washing side multiple times without washing his hands. EI #8 also said EI #9 bent down to tie his shoe and did not wash his hands prior to returning to the clean dish washing side. EI #8 continued and said EI #9 started putting up the clean dishes. EI #8 was asked what was the problem/concern with handling dishes in the manner observed by this surveyor on 4/18/18. EI #8 replied a potential for cross contamination, infection control, food borne illness and bacterial growth. EI #8 was asked why should hand washing be performed when moving from the dirty dish area to the clean dish area. EI #8 replied to prevent cross contamination. EI #8 continued and said the policy was they should wash their hands anytime there was potential for cross contamination.",2020-09-01
44,PLANTATION MANOR NURSING HOME,15015,6450 OLD TUSCALOOSA HIGHWAY   P O BOX 97,MC CALLA,AL,35111,2018-04-19,842,D,0,1,K9LV11,"Based on medical record review, interviews, and a review of a facility policy titled, Incident and Accident Report, the facility failed to ensure an incident/accident report regarding a fall RI (Resident Identifier) #45 sustained on 2/14/18 was done. This affected RI #45, one of two residents sampled for falls. Findings Include: A review of an undated facility policy titled, Incident and Accident Report, revealed: Purpose: Incident and accident reports are filled out to study the cause of an accident or incident and to take corrective action. Policy: The incident and accident form is to be filled out immediately by LPN (Licensed Practical Nurse) Charge Nurse, department head or supervisor when notified of an injury or accident. Procedure: [NAME] If an incident or accident occurs: . 4. If the incident involved a resident, chart the information required including: Sponsor (who and when Notified) Time the physician was notified Resident vital signs . During the review of the fall reports, the surveyor was made aware by the facility RI #45 had a fall on 2/14/18. A review of RI #45's medical record revealed no incident/accident report for the fall sustained on 2/14/18. An interview was conducted with EI (Employee Identifier) #6, a LPN (Licensed Practical Nurse), on 4/19/18 at 3:33 PM. EI #6 was asked who was responsible for documenting resident information in the medical record and she answered, The Nurse. EI #6 was asked who should have documented the fall RI #45 had on 2/14/18. EI #6 answered, The Nurse that responded. EI #6 was asked who was the nurse that responded and she answered, Me, I was the Nurse. EI #6 was asked why was this not done. EI #6 answered, I had started it and had a medical emergency and had to leave the facility. EI #6 was asked what she documented prior to leaving. EI #6 answered she had documented everything except for the notification part and she had not gotten the witness statement. EI #6 was asked where was that documentation. EI #6 answered, We think it must have gotten lost. EI #6 was asked where she last saw the incident form. EI #6 answered, In the med room on East wing on the desk. EI #6 was asked what was the facility's policy regarding complete and accurate documentation in the medical record and she answered, For it to be done and correctly. EI #6 was asked what was the concern of documentation not being entered into the medical record. EI #6 answered, Patient safety because we need to know. EI #6 was asked who was responsible for ensuring documentation was completed and accurate and she answered everyone that documented. An interview was conducted with EI #5, the DON (Director of Nursing), on 4/19/18 at 3:46 PM. EI #5 was asked who was responsible for documenting resident information in the medical record and she answered, The Charge Nurses. EI #5 was asked who should have documented the fall RI #45 had on 2/14/18. EI #5 answered, The Charge Nurse. EI #5 was asked who was the Charge Nurse and she answered EI #6. EI #5 was asked why this was not done and she answered, I don't know. EI #5 was asked what was the facility's policy regarding completed and accurate documentation in the medical record. EI #5 answered, That it should be done and accurate. EI #5 was asked what was the concern of documentation not entered into the medical record. EI #5 answered, That something may have happened that no one is aware of. EI #5 was asked who conduced fall investigations and she answered, The Charge Nurse initiates including witness statements and the restorative nurse initiates interventions. EI #5 was asked if was done for RI #45's fall and she answered yes, but it was not documented. EI #6 was asked how can verification be obtained that a fall was investigated if there was no documentation. EI #5 repeated there was no documentation. EI #5 was asked who was responsible for ensuring documentation was completed and accurate. EI #5 stated she was responsible.",2020-09-01
45,PLANTATION MANOR NURSING HOME,15015,6450 OLD TUSCALOOSA HIGHWAY   P O BOX 97,MC CALLA,AL,35111,2019-05-02,695,D,0,1,X13O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and facility policies titled, Oxygen Concentrator and Oxygen Administration, facility failed to ensure Resident #54's nasal cannula tubing was labeled with a date and the tubing connecting the concentrator with the water bottle were not out of date. This had a potential to affect of one of three residents observed receiving oxygen therapy. Findings include: A review of the facility's policy titled, OXYGEN CONCENTRATOR, with no effective date, revealed: . Policy Explanation and Compliance Guidelines: 5. Care of the Concentrator . c. i. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. .iii. If applicable, change nebulizer tubing and delivery devices every seventy-two hours. A review of the facility titled, Oxygen Administration, with no effective date, revealed: . Policy Explanation and Compliance Guidelines: . 5. d. If applicable, change nebulizer tubing and delivery devices every 72 hours and as needed if they become soiled or contaminated . RI# 54 was admitted to facility on 10/13/17 and readmitted on [DATE] with [DIAGNOSES REDACTED].>[MEDICAL CONDITION], acute and chronic [MEDICAL CONDITION] with hypercapnia, acute and chronic [MEDICAL CONDITION] with [MEDICAL CONDITION], and obstructive sleep apnea. On 04/30/19 at 09:56 am, the Surveyor observed Resident # 54 with oxygen, per nasal cannula, with no date on the nasal cannula tubing. The tubing connecting the concentrator and water bottle, dated 2/11/19, was handwritten on the tubing. The water bottle was dated 4/26/19. On 04/30/19 at 12:04 pm, the Surveyor observed Resident # 54 with oxygen per nasal cannula, with no date on the cannula tubing and a date of 2/11/19 was handwritten on the tubing connecting the concentrator and the water bottle. On 05/01/19 at 04:19 pm, the Surveyor observed Resident # 54 with oxygen in use by nasal cannula. No date was written on the nasal cannula tubing or the tubing connecting the concentrator with the water bottle. The water bottle was dated 5/1/19. On 05/02/19 01:18 PM, the Surveyor interviewed the Director of Nursing Employee Identifier (EI) #1. The Surveyor asked how often was the nasal cannula tubing and concentrator tubing changed. EI #1 replied, once a week. The Surveyor asked did they have a place to document the tubing changes. EI #1 replied, no. It should be written on the tubing. The Surveyor asked, if there was oxygen tubing that was dated for (MONTH) 11, 2019, handwritten, what would that date represent. EI#1 replied, that would be the date that it was changed. The Surveyor asked, if the oxygen tubing was dated (MONTH) 11, 2019, and was observed on 4/30/19, would that be considered correct, per facility policy. EI #1 replied, no it would not. The Surveyor asked, what specific tubing was changed weekly. EI #1 replied, the nasal cannula. The tubing connecting the concentrator to the water bottle was changed every three to four days. The Surveyor asked, was it a requirement of the staff to hand write the date of change on the tubing. EI #1 replied, yes. The Surveyor asked, how did they know if the tubing had been changed. EI #1 replied, by the date written on the tube. The Surveyor asked, what was the potential harm in not changing the oxygen tubing. EI #1 replied, infection.",2020-09-01
46,ATHENS HEALTH AND REHABILITATION LLC,15016,611 WEST MARKET STREET,ATHENS,AL,35611,2017-06-01,371,F,0,1,QJHS11,"Based on observations, review of the facility's policy titled: Food Cooking and Serving Temperatures dated (MONTH) 25, 2012, review of the 2013 Food Code and interviews with facility staff, the facility failed to ensure: 1. The thermometer was calibrated correctly prior to taking food temperatures on the tray line. 2. Monitored all foods on the tray line. 3. No use by dates on frozen shakes. 4. No dish racks were stored on the floor in the dish washing area. 5. Dishware (sectioned plates) were free of food debris, chips and stains. 1. Thermometer Calibration A facility policy titled: Food Cooking and Serving Temperatures with an effective date of 5/25/2012 revealed: . PURPOSE: Safe and sanitary food handling practices include effective control of food temperatures, in order to prevent food borne illnesses. STANDARD: According to federal regulations, food should be prepared according to tested recipes; .utilizing correct methods to conserve nutritive value and retain quality, .; and should be served attractively at proper temperatures. PR[NAME]ESS: . III. General Guidelines: a. A calibrated thermometer should be used for taking food temperatures. The final bullet under General Guidelines states,[NAME]center of food items . The 2013 Food Code revealed: 4-201.11 Good Repair and Calibration. (B) FOOD TEMPERATURE MEASURING DEVICES shall be calibrated in accordance with manufacturer's specifications as necessary to ensure their accuracy . On 5/31/2017 at 10:45 AM, an observation was made during the calibration of the thermometers. The thermometer was placed inside a cup filled with ice only and no water. On 6/1/2017 at 10:55 AM, an interview was conducted with EI #4, Certified Dietary Manager (CDM). EI #4 was asked what was the standardized methods for thermometer calibration. EI #4 said, to use ice and water. EI #4 was asked why did the cook fail to follow the standardized method on 5/31/2017. EI #4 said, carelessness. EI #4 was asked how did this affect the accuracy of the food temperatures. EI #4 said, if the thermometers were not properly calibrated, the food temperatures could not assured to be correct. 2. Monitor and document temperatures of all foods. The 2013 Food Code 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding revealed . (A) (1) At 57*C (Celsius) (135*F (Fahrenheit) or above . On 5/31/2017 at 10:45 AM temperatures were observed on the tray line. When obtaining food temperatures poor placement of the thermometer was used. The thermometer was not placed in the middle of the food where the temperature was being taken and the temperature was obtained and documented prior to placing the food on the tray line. During a second observation on 5/31/17 at 11:15 AM, a temperature was not taken of the hamburger patties and mashed potatoes on the tray line. On 6/1/2017 at 10:55 AM an interview was conducted with EI #4, CDM. EI #4 was asked did the staff ensure all foods, hamburger patties and mashed potatoes, were maintained at 135*F. EI #4 said, no. EI #4 was asked how did the deficient practice affect the residents. EI #4 said the potential for bacterial growth due to the hot foods not at an accurate temperature. 3. Frozen and thawed shakes. The 2013 Food Coded revealed: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (B) . CLEARLY MARKED, AT THE TIME THE ORIGINAL CONTAINER IS OPENED IN A food establishment AND IF THE food IS HELD FOR MORE THAN 24 (TWENTY FOUR) HOURS, TO INDICATE THE DATE OR DAY BY WHICH THE food SHALL BE CONSUMED ON THE premises . On 5/31/2017 at 5:45 PM an observation was made of 4 ounce shakes. 5 of 28 shakes on resident's meal trays in the dining room were observed with a label date of 5/28 without a discard date. On 6/1/2017 at 10:55 AM, an interview was conducted with EI #4, CDM. EI #4 was asked what was the Food Code requirement for labeling items with an expiration date. EI #4 said, should be dated with date of expiration. EI #4 was asked how did the facility label the shakes. EI #4 said, with the thawed date. EI #4 was asked what was the potential negative outcome. EI #4 said, potential for bacterial contamination. 4. Potential for cross contamination. On 5/30/2017 at 5:45 PM an observation was made in the dish washing area. Four dish racks were observed on the floor beneath the sink. On 5/30/2017 at 5:45 PM an interview was conducted with Employee Identifier (EI) #1, Cooks Helper. EI #1 was asked why were the dish racks on the floor. EI #1 said, I just put them there earlier and forgot to pick them up. On 6/1/2017 at 10:55 AM, an interview was conducted with EI #4, CDM. EI #4 was asked, when dish racks were not in use, where should they be stored. EI #4 said, the dish racks should be stored on a rolling dollie under the sink. EI #4 was asked why the dish racks were laying on the floor and not on a rolling dollie. EI #4 said, carelessness. EI #4 was asked what was the potential harm to residents when dish racks are placed on the floor and not on a rolling dollie. EI #4 said, potential for bacterial contamination. 5. Poor cleaning and sanitizing of equipment. The 2013 Food Code revealed: . 4-601.11 Equipment FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch . On 5/31/2017 at 10:55 AM, an observation was made of stored sectional plates. One of five plates were badly stained and four of the plates were observed with food adhered to the surface area and two plates were chipped. On 5/31/2017 at 10:55 AM, an interview was conducted with EI #2, Cook. EI #2 was asked what did she see on the plates. EI #2 said, It is dirty and stained. On 5/31/2017 at 10:55 AM, an interview was conducted with EI #3, Kitchen Manager. EI #3 was asked what did she see on the plates. EI #3 said chipped and somebody put it up dirty. On 6/1/2017 at 10:55 AM an interview was conducted with EI #4, CDM. EI #4 was asked what condition were the sectional plates found in. EI #4 said, stained, chipped with food debris. EI #4 was asked how did those things happen. EI #4 said the staff failed to properly inspect prior to stacking in storage. EI #4 was asked what was the potential negative outcome for the stained, chipped and food on plates. EI #4 said, unappetizing for the residents and potential for cross contamination.",2020-09-01
47,ATHENS HEALTH AND REHABILITATION LLC,15016,611 WEST MARKET STREET,ATHENS,AL,35611,2017-06-01,441,D,0,1,QJHS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with facility staff and review of a facility policy titled, Infection Prevention & (and) Control and Potter and Perry, Fundamentals of Nursing. The facility failed to ensure a licensed staff member did not place her ungloved fingers inside a medication cup during medication pass. This affected one of ten residents observed during medication pass. A facility policy titled: Infection Prevention & Control Section: General Infection Prevention .with an effective date of (MONTH) 1, 2009 revealed: PURPOSE: To provide guidelines to employees . that will aid in the prevention of the transmission of infections . Potter and Perry, Fundamental of Nursing, Ninth Edition, Copyright (YEAR), Unit V (five), page 448 revealed: . NURSING KNOWLEDGE BASE . The meticulous of specific infection prevention practices reduces the risk of cross-contamination and transmission of infection . An unsampled resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/31/2017 at 4:30 PM, Employee Identifier (EI) #5, License Practical Nurse (LPN) placed her ungloved fingers inside a medication cup to pick it up. She placed four medications inside the cup and provided the medication to the unsampled resident. On 5/31/2017 an interview was conducted with EI #5, LPN. EI #5 was asked how did she pick up the medication cup when preparing medications for the unsampled resident. EI #5 said, she placed her fingers inside the cup. EI #5 was asked how should a medication cup be picked up. EI #5 said, from the bottom. EI #5 was asked should ungloved fingers be placed inside the medication cup when picking the cup up. EI #5 said, never. EI #5 was asked what was the potential harm to a resident when ungloved fingers are placed inside a medication cup. EI #5 said, transfer of bacteria. On 6/1/2017 at 8:33 AM, an interview was conducted with EI #6, LPN/Infection Control. EI #6 was asked how should a licensed nurse retrieve a medication cup during medication pass. EI #6 said, sides and bottom. EI #6 was asked was it an appropriate practice of that facility for a licensed nurse to place her ungloved fingers inside of a medication cup to pick it up. EI #6 said, no. EI #6 was asked what was the potential harm to residents when a licensed nurse placed her ungloved finger inside of a medication cup when it was picked up. EI #6 said, transmission of infection and bacteria.",2020-09-01
48,ATHENS HEALTH AND REHABILITATION LLC,15016,611 WEST MARKET STREET,ATHENS,AL,35611,2018-07-19,656,D,0,1,OEFS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review and a review of the facility's policy and procedure titled, Person Centered Care Plans, the facility failed to ensure staff developed a comprehensive care plan for a regular diet with nectar thickened liquids. This deficient practice affected RI (Resident Identifier) #24, 1 of 29 sampled residents. Findings Include: Review of the facility's policy titled Person Centered Care Plans dated (MONTH) (YEAR) states, PURPOSE: Person centered care plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches approaches and goals of the resident,,,. RI #24 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. On 7/18/18 at 8:00 AM an observation of RI 24's tray was made with EI # 4, Certified Nursing Assistant (CNA) present. EI #4 stated the resident was on nectar thickened liquids but did not know why. On 7/18/18 at 8:42 AM, RI #24's chart was reviewed with EI #2, Registered Nurse (RN) Supervisor of East I. The surveyor asked EI #2 what diet RI #24 was currently receiving according to physician's orders [REDACTED].#2 stated that from the 7/10/18 orders and readmission, the resident is on a regular diet with nectar thickened liquids. On 7/18/18 at 9:08 AM, an interview was conducted with EI #3, the Certified Dietary Manager (CDM). The surveyor asked what diet was the resident on when he was readmitted on [DATE]. EI #3 reviewed a dietary Communication Form dated 7/17/18 and said that she got a communication form from EI #2, the RN Unit Manager, putting RI #24 on a regular diet with nectar thick liquids. 07/19/18 09:38 AM an interview was conducted with EI #13, the MDS/Minimum Data Set Coordinator, The surveyor asked who is responsible for the care plan for diet changes. EI #13 stated, it is the unit manager or the person taking that order off. The surveyor asked where the care plan was for RI #24's diet for thickened liquids after readmission on 7/10/18. EI #13 said there is no care plan. The surveyor asked what was the purpose of a care plan. EI #13 stated it was to inform the resident, family and staff of the plan of care for that resident. EI #2, the RN Unit Manager was asked on 7/19/18 at 9:51 AM during an interview, what care plan was put in place on RI #24's admission on 7/10/18 regarding nectar (thickened) liquids. EI #2 stated, there should have been a care plan for a regular diet with nectar thickened liquids. Care plans were reviewed with EI #2 at this time and there was no diet care plan. The surveyor asked EI #2, after she sent a dietary communication form dated 7/17/18, what care plan did she put in place. EI #2 said she did not put a care plan in place. The surveyor asked EI #2 if she should have put a diet care plan in place. EI 2# stated, she should have. The surveyor asked what the purpose of a care plan is when there is a change in the residents care per physician's orders [REDACTED].#2 stated, So that every one knows the plan of care for that patient to ensure that the resident is receiving what the doctor has ordered. The surveyor asked was that done for RI #24. EI #2 stated, No.",2020-09-01
49,ATHENS HEALTH AND REHABILITATION LLC,15016,611 WEST MARKET STREET,ATHENS,AL,35611,2018-07-19,658,D,0,1,OEFS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, medical record reviews, review of Potter and Perry's Fundamentals of Nursing, Ninth Edition and a facility policy titled Medication Administration Guidelines, the facility failed to ensure licensed nursing staff, Employee Identifier (EI) #14, followed Resident Identifier (RI) #25's Physician order [REDACTED]. This deficient practice affected RI #25, one resident observed receiving eye drops. Finding Include: 1. A review of Potter and Perry's Fundamentals of Nursing, ninth edition, with a copyright date of (YEAR), Chapter 23, Legal Implications in Nursing Practice, page 311, documented: . Health Care Providers' Orders . Nurses follow health care providers' orders unless they believe that the orders are in error . RI #25 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the medical record for RI #25 revealed the following Physician order [REDACTED]. . REFRESH [MEDICATION NAME] 1% EYE DROPS INSTILL TWO DROPS IN BOTH EYES THREE TIMES A DAY FOR DRY EYES, ARTIFICIAL TEARS --- (HOUSE ST[NAME]K) GIVE 1 DROP OU (BOTH EYES) AT BEDTIME NIGHTLY . On 7/18/18 at 9:00 a.m., during the Medication Administration Observation, the surveyor observed EI #14, the medication nurse administer Artificial Tears, two drops in each eye of RI #25. The medications were reconciled by the surveyor via (by way of) RI #25's Physician order [REDACTED]. The physicians's orders revealed EI #25 had not followed the physician orders [REDACTED].#25. The eye drops which were ordered and scheduled for this time (9:00 a.m.) were REFRESH [MEDICATION NAME] 1% EYE DROPS. On 07/18/18 10:56 AM, the surveyor conducted an interview with EI #14. The surveyor asked EI #14 if she administered RI #25 Artificial Tears 2 drops (gtts) in ou (both eyes), or Refresh [MEDICATION NAME] 1% eye gtts. EI #14 said she did not give RI #25 the Refresh eye drops. EI #14 said she has never given RI #25 gel eye drops(Refresh [MEDICATION NAME] 1% eye gtts). EI #14 said she always gave RI #25 Artificial tears. The surveyor asked EI #14, according to RI #25's Physician orders, what eye drops should RI #25 receive? EI #14 said, the Refresh [MEDICATION NAME] 1% three times a day.",2020-09-01
50,ATHENS HEALTH AND REHABILITATION LLC,15016,611 WEST MARKET STREET,ATHENS,AL,35611,2018-07-19,661,D,0,1,OEFS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and a review of the facility's policy titled, Discharge Summary and Plan of Care, the facility failed to ensure licensed staff completed a discharge summary for RI (Resident Identifier) #113's discharge from the facility. This was evident during the review of 1 of 4 discharges. Findings Include: The facility's policy titled Discharge Summary and Plan of Care dated 11/28/16 states: Purpose: Appropriate discharge planning and communication of necessary information to the continuing care provider, after discharge of a resident/guest from the facility, help the new care provider understand the resident/guests goals and needs. The process in this policy includes what the dscharge smmary should include which is: *A recapitulation of the residentguest's stay *A final summary of the resident/guest's status at the time of discharge *A post discharge plan of care developed with the resident/guest and his/her family which will assist the resident/guest to adjust to his/her new living environment . Medical review review conducted for RI # 113 revealed this resident was admitted to the facility on [DATE] and was discharged from the facility on 5/24/18. An interview was conducted with Employee Identifier (EI) #6, LPN/Licensed Practical Nurse, Charge nurse on 07/19/18 12:15 PM. The surveyor asked where the discharge summary was for RI #113. EI #6, stated, there was no d/c summary for RI #113. The policy and procedure regarding discharge summaries was referenced with EI #6, and asked if the resident should have a discharge summary. EI #6 stated, Yes. When EI #6 was asked if the discharge summary policy and procedure was followed, EI #6 stated, No.",2020-09-01
51,ATHENS HEALTH AND REHABILITATION LLC,15016,611 WEST MARKET STREET,ATHENS,AL,35611,2018-07-19,687,D,0,1,OEFS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure the nails of Resident Identifiers (RI) #3 and #31 were maintained in a trimmed condition. This affected two of five sampled residents for whom an observation of the feet and toes was made. Findings included: The facility policy titled, Nail Care dated (MONTH) 1, 2010, cites the purpose as: Routine nail care helps reduce the potential for infection, prevents intrusion of the nail into the skin, prevents possible injuries and promotes a feeling of well being for the resident. The standard specifies: Nail care is a routine part of grooming each day. Foot care should be provided as a part of a tub or shower bath. The policy further recommends .a Podiatrist provides foot care for residents with Diabetes or [MEDICAL CONDITION] . 1) RI #3 has resided in the facility since 11/06/17, with [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 07/12/18, identified RI #3 as cognitively intact. The care plan related to Activities of Daily Living for RI #3, (dated 11/07/17) included, Nail care as needed. During an interview on 07/17/18 at 8:44 AM, the surveyor questioned RI #3 about the care of his/her feet. In response, RI #3 removed his/her shoes. The toenails on RI #3's left foot were long, particularly the great toe, which extended approximately 1/2 beyond the end of the toe. When questioned further, RI #3 explained he/she had been on the list to see the facility podiatrist for nearly a year, and had made numerous requests for podiatry assistance. On 07/18/18 at 5:05 PM, the facility Administrator, Employee Identifier (EI) #1 accompanied the Surveyor to RI #3's room, and viewed his/her feet. When asked, EI #1 stated it was the nurses' responsibility to ensure each resident's toe nails were trimmed. EI #1 then affirmed the nails on the resident's left foot (particularly the great toe) were in need of a trim. EI #1 described the left great toe nail as long, thick and curled. When asked if she knew when RI #31's toenails were last trimmed and by whom, EI #1 did not know. The resident stated he/she had someone cut the toenails about three months earlier, When asked if she knew why RI #3's toenails had not been trimmed before now, EI #1 did not know--and in particular, the great toenail. In response to a question of potential harm in failing to keep RI #3's nails in a trimmed condition, EI #1 said the toenail could break and cause discomfort. The resident (RI #3) added, the toenail could curl around and cause pain. 2. RI #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. On 7/18/18 at 11:21 AM, an observation of the toenails were made by the surveyor along with EI #10, RN, Unit Manager. This observation revealed that on the right foot, the right great toe and 4th toe needed cutting along with the 3rd, 4th and 5th toes on the left foot needing cutting. EI #10 stated at the time of the observation that the toes needed clipping and described the toenails as curled onto themselves and usually a Podiatrist cuts the toenails. EI #10 was asked what the potential for harm was. EI #10 stated that RI #31 could scratch him/herself, could get infected, or have ingrown toe nails. When EI #10 was asked if RI #31 should be on the Podiatrist list, she responded by saying, yes he should be. When asked how often the Podiatrist comes, RI #10 stated she though every 3 months. Review of the medical record revealed RI #31 had seen the Podiatrist on 11/1/17 and on 2/22/18.",2020-09-01
52,ATHENS HEALTH AND REHABILITATION LLC,15016,611 WEST MARKET STREET,ATHENS,AL,35611,2018-07-19,755,D,0,1,OEFS11,"Based on observations of medication storage on 3 of 5 units, and review of the facility's policy titled Medication Storage, Storage of Medications and Biologicals, the facility failed to ensure that medications that were expired were not available for use. Expired medications were located on one of the three units observed. Findings include: Review of a facility policy titled Medication Storage, Storage of Medications and Biologicals, Policy 3.1, 03/11 states: Policy Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . Procedures 11. Outdated, contaminated or deterioriated medications and those in containers that are cracked, soiled, or without secure clusures are removed from stock, disposed of according to procedures for medications disposal . During an observation on 7/18/18 at 2:39 PM, with EI #9, a Licensed Practical Nurse (LPN), of the rehab. medication storage room, two vials of flu vaccine were observed. These two vials had expiration dates of 6/22/18. During an interview with EI #9, on 7/18/18 at 2:43 PM, she was asked who is responsible for removing expired medications. EI #9 said, any of the nurses (could remove expired medications). When asked if there is a potential for harm for administering expired medications, EI #9 responded by saying, they could have a reaction. When asked if expired medications should be in the refrigerator, EI #9 said, no.",2020-09-01
53,ATHENS HEALTH AND REHABILITATION LLC,15016,611 WEST MARKET STREET,ATHENS,AL,35611,2018-07-19,880,D,0,1,OEFS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and a review of the facility policies titled Hand Hygiene, Blood Glucose/PT/INR Machine Cleaning Guidelines, and Using Gloves, this facility failed to ensure that infection control practices were utilized to prevent the spread of infection. This deficient practice had the potential to affect 3 of 3 residents, RI #'s 57, 49 and 313. Findings include: A review of the facility's policy Infection Prevention & Control Manual, Policy Title: Hand Hygiene, effective date (MONTH) 1, (YEAR), Purpose: To provide guidelines to employees for proper and appropriate hand washing techniques that will aide in the prevention of the transmission of infections. Standard: Hand washing should be performed between procedures with resident/guest(s) based upon the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucus membranes may contain transmissible infectious agents. III. Hand Hygiene Hand hygiene continues to be the primary means of preventing the transmission of infections. The following is a list of some situations that require hand hygiene. * .before and after direct residnet/guest contact . Before and after perfoerming any invasive procedure (e.g. fingerstick blood sampling). A facility policy titled, Using Gloves dated (MONTH) 1, 2009 revealed, Standard: Gloves should be worn when . possibly infectious materials are anticipated. A facility document titled Blood Blucose/PT/INR Machine Cleaning Guidelines with a revision date of 11/5/11 included the following: 3. Don first pair of gloves, do procedure, place glucometer on contaminated towel/surface. 4. Wash hands and put on a second pair of gloves. 5. Clean glucometer with disinfectant wipe, place on clean surface . EI (Employee Idenntifier) #7 Licensed Practical Nurse (LPN), was observed during the medication pass observation on 7/17/18 at 3:39 PM. 1. At 3:45 PM, EI #7 performed a finger stick blood sugar (FSBS) on RI #57. After obtaining the FSBS, EI #7 was observed to remove her gloves, and not perform hand hygiene. EI #7 cleaned the glucometer with her bare hands and placed the glucometer bck on the same barrier (unclean surface). Hand hygiene was not performed until after the staff cleaned the glucometer. 2. At 3:56 PM, EI #7 obtained a FSBS on RI #49. EI #7 was then observed to reach down into a magazine basket with her gloved hand. After EI #7 removed her gloves and cleaned the glucometer before performing hand hygiene. 3. On 7/17/18 at 4:05 PM, hand hygiene was not done before putting on gloves and performing a FSBS on RI #313. At 4:10 PM, EI # 7 cleaned the glucometer but did not do hand hygiene till after she cleaned machine. EI #7 gave RI #313 insulin but did not wear gloves while doing so. Again at 5:02 PM, EI #7 gave RI #313 insulin and did not wear gloves. [MEDICATION NAME] 10 units in the right upper abdomen, no gloves were worn. On 7/18/18 at 4:29 PM, an interview was conducted with EI #7, LPN. EI #7 was asked when she should wash her hands during med pass? EI #7 replied, before and after each med pass and each resident. EI # 7 was asked, what is the potential for harm of not performing hand hygiene? EI #7 replied infection, bacteria, and spreading germs. On 7/18/18 at 4:29 PM, EI #7 was asked what she should have done before cleaning the glucometer? EI # 7 replied, put on gloves EI #7 was asked, what should you do before putting soiled glove in a resident's magazine rack? EI #7 replied, I don't know, took that glove off and put another glove on. When asked what should be worn before you give an injection? EI #7 replied, Gloves. When asked what is the potential for harm? EI # 7 replied,spreading germs. On 7/18/18 at 4:07 PM, an interview was conducted with EI #5, the Director of Nursing (DON). EI #5 was asked, during med pass, when should the nurse wash their hands? EI#5 replied, when they enter the room, before they prepare medications, and if they touch anything they need to (wash their hands) before they go back to the med cart. EI #5 was asked what should be done before putting a soiled gloved hand in resident's magazine rack? EI #5 replied, Remove glove before touching anything in the environment. EI #5 was asked, what should be worn before you give an injection? EI #5 replied, Need to have gloves on. EI #5 was asked, what is the potential harm? EI #5 replied, infection to the residents.",2020-09-01
54,ATHENS HEALTH AND REHABILITATION LLC,15016,611 WEST MARKET STREET,ATHENS,AL,35611,2019-08-29,580,D,1,1,39OM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of a facility policy titled, Change in Medical Condition of Resident/Guest(s), the facility failed to ensure Resident Identifier (RI) #272's family/responsible party was notified of a new order written on 4/19/19, for [MEDICATION NAME] DR (Delayed Release) 125 MG (milligrams) sprinkle by mouth at hour of sleep. This deficient practice affected RI #272, one of 25 sampled residents. Finding Include: A facility policy title: Change in Medical Condition of Resident/Guest (s), with an effective date of 11/28/2016 revealed the following: .STANDARD: Notification . legal representative, or interested family member, should occur promptly, according to federal regulations, when there is a change in the resident/guest (s) condition, . *A need to alter treatment . to commence a new form of treatment . RI #272 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #272 Physician order [REDACTED]. The orders also included an order for [REDACTED]. On 8/29/19 5:52 p.m., the surveyor conducted an interview with Employee Identifier (EI) #3, Registered Nurse Unit Manager/Supervisor. The surveyor asked EI #3 was there an order for [REDACTED].#3 how could she verify that an order had been given. EI #3 stated what she had been told by this company was that you do not have to have a written order, you can put verbal orders directly into the computer. The surveyor asked EI #3 when did the physician write the order. EI #3 stated she did not know why the physician did not hand write the order. The surveyor asked EI #3 was this a usual practice. EI #3 stated, not generally. The surveyor asked was the family/responsible party notified of the new order. EI #3 stated it did not look like they were notified. The surveyor asked EI #3 where would the evident be that family was notified if there were evident. EI #3 stated in the nurses notes. The surveyor asked EI #3 was there evident in the nurses notes. EI #3 stated there was no record of it. The surveyor asked EI #3 who would have been responsible for notifying the family. EI #3 stated the nurse that put the order in. The surveyor asked did RI #272 receive [MEDICATION NAME] the entire time he/she was at the facility. EI #3 stated yes, it looked like he/she got it because they (nursing) were signing off that he/she got it. The surveyor asked EI #3 was there a new order for additional [MEDICATION NAME] 20 MG to be given on 4/24/19 for three days. EI #3 stated yes, give [MEDICATION NAME] 20 MG tablet by mouth at noon daily times three days in addition to morning dose. The surveyor asked EI #3 why was there a new order for the additional [MEDICATION NAME] 20 MG on 4/24/19 to be given one everyday at noon for three days. EI #3 stated she did not know, she guest the resident had some [MEDICAL CONDITION]. The surveyor asked EI #3 where would there be evident that the family was notified of that new order. EI #3 stated the LPN (License Practical Nurse) that took the order off should have notified the family. The surveyor asked EI #3 where did she note it in her notes. The surveyor gave EI #3 a copy of the nurse's notes. EI #3 stated it did not look like there was a note. This citation is written as a result of the investigation of complaint/report #AL 292.",2020-09-01
55,ATHENS HEALTH AND REHABILITATION LLC,15016,611 WEST MARKET STREET,ATHENS,AL,35611,2019-08-29,602,E,1,1,39OM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, record reviews and a review of a facility policy titled, Abuse Prevention, the facility failed to ensure resident narcotic medications were not missing. This deficient practice affected RI #87, #48, #222, #223 and #224, five of five residents who were investigated for missing narcotic medication. Findings Include: A review of a facility policy titled Abuse Prevention, with an effective date of [DATE] , revealed: The following are definitions of specific types of abuse: . D) Misappropriation of Resident/ . Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's . belongings or money without the resident's consent . (1) RI #87 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. A review of RI #87's (MONTH) 2019 Medication Administration Record [REDACTED]. [DATE] 6:35 pm, an interview with Employee Identifier (EI) #15, Licensed Practical Nurse(LPN) Charge Nurse was conducted. EI #15 was asked was she familiar with RI #87. EI #15 said yes. EI #15 was asked when she worked on [DATE] did RI #87 complain of pain during her shift. EI #15 said RI #87 sometimes would, he/ she would say his/ her head hurt or he/ she hurt all over. EI #15 was asked when was the last time she had to give RI #87 pain medication. EI #15 said she did not remember, hospice started the medication and she may have given pain medication one time. EI #15 was asked what was the narcotic. EI #15 said it was [MEDICATION NAME]. EI #15 was asked was RI #87 presently on this drug. EI #15 said no, it was stopped. EI #15 was asked what, if any, did RI #87 take for pain since the [MEDICATION NAME] had been stopped. EI #15 said if RI#87 needed pain medication, RI #87 will take a Tylenol. EI #15 was asked how did she know RI #87 was missing pain medication. EI #15 said because she fussed about it everyday, because she had to count that many pills every day; hospice sent a lot of narcotics so on that day she did not have many to count, so when she counted with EI #16 at the start of her shift, she noticed one card was gone. EI #15 was asked what did she say to EI#16. EI #15 said she looked and said to EI #16, RI #87 was missing a card of medication. EI #15 said EI #16 attempted to change the subject, so EI #15 said she went to the nurse and asked her did she sign with EI #16 zeroing the card out. EI #15 said she showed another nurse the paper, that nurse said that was not her signature on the form. EI #15 said she then called EI #2, Assistant Director of Nursing (ADON) and she said to keep EI #16 there and to call the Director Of Nursing (DON). EI #15 said told the ADON she could not keep EI #16 there. EI #15 was asked when she worked, had she known of narcotics being missing before this incident. EI #15 said no, she had not. EI #15 was asked what was the procedure for counting narcotics. EI #15 said the oncoming nurse count with the off going nurse, they call out the resident name, narcotic name and the amount of tablets, then the oncoming nurse will say out loud the number of tablets and both nurse's will look at the narc book, both nurse's sign the sheet; they are not supposed to take the keys until the count is correct. EI #15 was asked how did she know the sheet was wrong. EI #15 said the entire sheet and card was gone; EI #16 took a narcotic log sheet and wrote zero on that sheet. (2) RI #222 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. A review of RI #222's (MONTH) 2019 MAR indicated [REDACTED]. On [DATE] at 10:15 am, the surveyor conducted an interview with EI # 9 LPN. EI #9 was asked when working on [DATE], while counting the narcotic for RI # 222, was there any narcotic medication discrepancy. EI #9 said no. EI #9 was asked how was she made aware of the missing narcotic for RI #222. EI #9 said her DON made her aware and she gave a statement. EI #9 was asked what was the procedure for counting narcotics. EI #9 said the same procedure as they had before and after in the case of RI #224. EI #9 was asked did she have any knowledge of the missing medication for RI #224. EI #9 said no she did not. EI #9 was asked was she aware of any staff members taking residents narcotic medication. EI #9 said no. On [DATE] at 1:55 pm, an interview with EI #7 Registered Nurse (RN). EI #7 was asked was she familiar with RI #223 and RI #222. EI #7 said yes. EI #7 was asked what knowledge did she have on missing narcotics cards for these residents. EI #7 said she worked for three or four days and the cart was full of narcotics then she was off for two days and when she came back, she noticed there was not as many cards, but there had been a lot of discharges and the cards may have been sent with the patients, so she did not think anything about the cards being gone because of the discharges. EI #7 said when she counted with the off going nurse she made her aware of the cards being missing on RI#223 and RI #222. EI #7 was asked who was the nurse. EI #7 said another nurse she was not sure of her last name, she was a RN that worked 3rd shift when ever necessary. EI #7 said after counting they both went to the DON. EI #7 was asked what happened next. EI #7 said they told the DON and gave a statement. EI #7 was asked while on her shift had she given RI #223 or RI #222 pain medication. EI #7 said yes. EI #7 was asked how did she count narcotics on her shift. EI #7 said they have to count the amount of cards and bottles, after that they have to count each individual card, bottle, boxes stating the resident's name, medication name and the amount, then they both sign. EI #7 was asked what was the old way. EI #7 said they count the number of tablets in the card or the amount of liquid narcotic, number of patches. EI #7 was asked how did this differ from the old process to the new process. EI #7 said they count each card, not just the tablet, for example they would count maybe, say 15 cards or five bottles. EI #7 was asked where was this documented. EI #7 said on the narcotic flow sheet found in the front of the book,they documented how many cards or bottles in the cart, each nurse sign this each shift, if they add or take away a card two nurses must sign. EI #7 was asked when she signed with EI #16 to zero out a card, what did she do. EI #7 said she signed. EI #7 was asked when she looked at the card were there any pills on the card. EI #7 said no. EI #7 was asked what was the resident name on the zeroed out card. EI #7 said she did not remember. EI #7 was asked had EI #16 asked her to do this before. EI #7 said she did not recall. EI #7 was asked did she have any knowledge of a staff member taking narcotics from the medication cart for personal use. EI #7 said no. EI #7 was asked did she have any knowledge of this incident. EI #7 said no. On [DATE] at 11:39 am, an interview with EI #13 LPN by phone, was conducted. EI #13 was asked was she familiar with RI # 223 and RI # 222. EI #13 said yes. EI #13 was asked what could she tell the surveyor about the missing narcotic medication. EI #13 said she could not tell the surveyor anything about missing medications. EI #13 was asked how did she count narcotics. EI #13 said before this incident one nurse would have the narcotic book and the other nurse would call out the number of pills on the card. EI #13 was asked how did she count narcotics now. EI #13 said the same way, but in addition they counted the number of cards of narcotic and keep a log both nurse's sign. EI #13 was asked did she have any knowledge of staff taking narcotics from the cart, EI #13 said no. On [DATE] at 6:00 pm, an interview with EI #14/LPN was conducted. EI #14 was asked was she familiar with RI #223 and RI #222. EI #14 said yes. EI #14 was asked when she worked with RI #223 and RI #222 did they ask her for pain medications. EI #14 said they normally asked at bed time. EI #14 was asked when they asked for pain medications did she have pain medication in the cart for these residents. EI #14 said yes. EI #14 was asked when was she made aware of medication, particularly narcotics being missing from the cart. EI #14 said when another nurse went to discharge RI #222 she noticed he/she was missing one card; the nurse asked her to co-sign with her. EI #14 was asked what happened next. EI #14 said the nurse called the DON. EI #14 was asked when RI #222 was discharged did he/she have narcotics to take home. EI #14 said yes. EI #14 was asked who may have taken one of RI #222 cards of narcotics. EI #14 said she did not know. EI #14 was asked when working her shift had any one told her about a staff member taking cards of narcotics. EI #14 said no. EI #14 was asked what was the procedure for counting narcotics. EI #14 said they count each card to make sure the number match the sheet, they match the name with the card, now they count all the cards in the cart to make sure they are in the cart; when narcotics come in they log them onto the narcotic sheet; when they take a card out they subtract from the narcotic sheet. EI #14 was asked how many nurse's must sign the narcotic sheet. EI #14 said two. (3) RI #223 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. A review of RI #223's (MONTH) 2019 MAR indicated [REDACTED]. On [DATE] at 10:15 am, an interview with EI # 9/LPN was conducted. EI # 9 was asked when working on [DATE], while counting narcotics for RI #223, were there any discrepancy with the narcotic count. EI #9 said no. EI #9 was asked how was she made aware of missing narcotic for RI #223. EI #9 said her DON made her aware and she gave a statement. EI #9 was asked what was the procedure for counting narcotics. EI #9 said the same procedure as before and after in the case of RI #224. EI #9 was asked did she have any information on missing narcotics for RI # 223. EI #9 said no she did not. EI #9 was asked was she aware of any staff members taking any resident's narcotic medications. EI #9 said she no. (4) RI # 48 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. A review of RI #48's (MONTH) 2019 MAR indicated [REDACTED]. On [DATE] at 8:25 am, an interview was conducted with EI # 12 LPN. EI #12 was asked what made her aware of RI #48 missing narcotics. EI #12 said because she thought she remembered seeing three cards and she noticed there was only two cards. EI #12 said she could not remember signing in three cards for RI #48 or if another nurse signed them in and she co-signed. EI #12 was asked what did she do next. EI #12 said the next morning she asked the day shift nurse if she removed a card of narcotics on RI #48. EI #2 said the nurse told her she had turned one card in to the DON. EI #12 said she asked the DON where was the paper that they had to sign, who ever takes the paper to the DON, they both have to sign; the nurse and the DON both have to sign when it is for destruction. EI #12 was asked what happened next. EI #12 said the DON started trying to tell her why they had to get the card out, the DON was telling her something about a new script. EI #12 said when she left EI #10 was looking for the paper. EI #12 was asked what happened next. EI #12 said she was still looking for the sheet and she said she would get the DON to sign the sheet. EI #12 said when she got home EI #10 called her and said EI #12 was right, that was not the card that was turned in, the prescription number did not match, the one that they destroyed. EI #12 said she kept saying she did not understand because all three cards came in together, so if one was expired all three would have been expired; EI # 10 kept saying no. EI #12 was asked why would EI #10 say no they had destroyed the drug. EI #12 said she believed EI #10 had it mixed up with some other drug. EI #12 said to EI #10 she and the DON need to find the sheets, but she did call and say that there was one card missing. EI #12 said she came back in the next night and she was told the DON had taken care of it. EI #12 was asked did she have any knowledge of any staff member taking the resident's narcotic. EI #12 said no. EI #12 was asked what was the procedure for counting narcotic. EI #12 said the old way was the oncoming nurse would be in the cart and the off going nurse would have the book calling out the resident name, drug name and how many. EI #12 was asked what was the new process. EI #12 said before they count the pills, the off going nurse will tell the oncoming nurse the total number of cards in the cart and then they will count, the oncoming will be counting in the cart and the offgoing nurse would be in the book calling out the resident name, drug name and number of tablets. EI #12 was asked did she have any other information to offer. EI #12 said no. EI #12 was asked who did she count off with on [DATE]. EI #12 said she thought it was EI #11. (5) RI #224 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. A review of RI # 224 (MONTH) 2019 MAR indicated [REDACTED]. On [DATE] at 9:45 am, an interview with EI # 9/ LPN was conducted. EI #9 was asked where was she working on [DATE] from ,[DATE] am. EI #9 said 1st East Hall. EI #9 was asked when she worked with RI #224 did she administer pain medications. EI #9 said no she did not. EI #9 was asked when she worked with RI #224 did she/ he complain of pain. EI #9 no. EI #9 was asked when her shift ended who did you count with. EI #9 said she counted with EI #3, she was the unit manager and was working that weekend she counted with her. EI #9 was asked what was the procedure for counting narcotics. EI #9 said the procedure then was she would stand at the book, oncoming nurse would stand at the narcotic drawer, she would call out the resident name, medication and number of tablets, the oncoming would verify what was on the card to what EI #9 called out and the oncoming would look at the book also to verify what EI #9 had called out. EI #9 was asked when she counted off on [DATE] were there any discrepancy with the medication narcotic count on this date. EI #9 said no. EI #9 was asked what was the new procedure for counting narcotics at the end of her shift. EI #9 said at the beginning and end of every shift they have a form that the oncoming and offgoing nurse will sign and it has to list how many cards are in the narcotic drawer, this included liquid bottle narcotic, narcotic patches, everything was accounted, for example if there was 23 narcotic in the drawer both nurse's sign and write 23, if a card was empty, there was a place to write the resident name, prescription number, name of the medication and both nurse's sign; there was a ledger that will say R-removed, D-destruction, the same procedure was used for receiving a medication to the cart, list resident name, medication name and prescription number. EI #9 was asked how was she made aware of the missing medications for RI #224. EI #9 said her DON called her in to give a statement. EI #9 was asked did she have any knowledge of the missing medications for RI #224. EI #9 said no she did not. On [DATE] at 12:09 pm, an interview was conducted with EI # 10/LPN Charge Nurse, by phone. EI #10 was asked when working with RI #224 did she administer pain medications. EI #10 said no. EI #10 was asked did RI #224 ask for pain medications during the day time. EI #10 said RI #224 took it at night to help rest. EI #10 said she thought she gave it a few times, here or there. EI #10 was asked when she worked with RI #224 did the resident complain of pain. EI #10 said the resident would sometimes and she offered the resident medication but RI #224 would decline, saying it would make him/ her drowsy, so he/ she would wait until night, due to therapy during the day. EI #10 was asked when her shift ended did she count with the oncoming nurse. EI #10 said yes, she counted at every shift change. EI #10 was asked what was the procedure for counting narcotics. EI #10 said there had to be two nurse's, oncoming and offgoing, the patient's name, medication name and number of pills. EI #10 was asked were the two nurse's required to sign. EI #10 said yes, the narcotic record sheet, both nurse's would sign that the count are correct and accounted for. EI #10 was asked when she counted at the end of her shift had she found any discrepancies with the narcotic count. EI #10 said no and if she had she would called the DON. EI #10 was asked was she aware of any missing medications. EI #10 said she was aware of RI #224 having missing medications and this had been reported. EI #10 was asked did she have any other knowledge of missing medication. EI #10 said she know medications were missing, it was reported, investigated and that nurse was reported to the Board of Nursing and the police was involved. EI #10 was asked was she aware of any nurse taking medications. EI #10 said she was not aware of this until the incident had occurred and being reported, she never suspected any nurse's of taking medications. On [DATE] at 4:54 pm, interview with EI #11/RN Charge Nurse. EI #11 was asked was she familiar with RI #48, RI #223 and RI # 224. EI #11 said she was familiar with RI #48. EI #11 was asked what could she tell the surveyor about missing narcotics on RI #48. EI #11 said she could not recall what happened but could remember RI #224. EI #11 was asked what happened with RI #224. EI #11 said it was a Sunday, she was not sure this was the day, she came to work, and EI #16 was working there; and EI #16 went to count, EI #11 counted all the narcotic and took the keys, it was in the evening. EI #11 said the resident asked for pain pills,so she went to the cart, opened the narcotic box and she figured out there was one more card that should have had some pills on it but it was not there, so she had to use a new card, she did not remember if some was used from the new card, she did remember, she had to use from a new card. EI #11 said the day shift nurse usually would remove the card and take it to the office, if the card was expired, but she was still thinking the card was not empty. She said she talked to EI #10 the next day and EI #10 agreed there should have been some left, on the same day EI #16 was working on the other hall, so EI #10 and herself called over to talk EI #16. EI #11 was asked what happened next. EI #11 said she and EI #10 asked EI #16 about RI #224 saying there was two cards. EI #11 was asked what did EI #16 say. EI #11 said, EI #16 said she emptied one card. EI #11 was asked what did she or EI #10 say. EI #11 said they asked her where was the sheet with two nurse's signing. EI #11 was asked what did EI #16 say. EI #11 said EI #16 said she put it on the top of the door rack to the med room, then she said she may have laid it on the desk. EI #11 was asked what did she say. EI #11 said they said okay, they searched and could not find it. EI #11 was asked what did she do next. EI #11 said EI #10 reported to the DON. EI #10 said she did not remove the card, she was sure then it was another card of medication. EI #11 was asked what was the procedure for counting narcotics during shift change. EI #11 said two nurse's have to count with the resident name, dosage, milligrams, drug name quantity and they both sign. EI #11 was asked what was the new procedure. EI #11 said they count the number of cards each resident have, when they remove the card two nurses write the resident name, drug name and both nurses sign it; when they receive the card both nurses will sign so every one will know what came in or went out. EI #11 was asked did she know of any staff member that have taken the resident medications particularly the narcotic. EI #11 said no except for this incident. EI #11 was asked what made her suspect EI #16 as being the person to remove the narcotic from the cart. EI #11 said because every hall EI #16 had worked something had been missing and EI #16 was changing her story. EI #11 said they never had this problem on their hall since she started working there. EI #11 was asked when did she think or hear of issues with narcotics being missing on other halls. EI #11 said it was when they looked at their cart, EI #10 and herself, then they started talking among themselves and they made night shift aware and they also said they noted issues on other halls. EI #11 was asked who on the night shift said they noticed missing medications. EI #11 said she did not remember, they did not have these types of issues on their hall since she started working there, until this happened. On [DATE] at 5:50 pm, an interview with EI #3/RN Unit Manager/Rehab was conducted. EI #3 was asked was she familiar with RI #224. EI #3 said she could not remember. EI #3 was asked was she familiar with RI #48. EI #3 said she was. EI #3 was asked what could she tell the surveyor about these resident missing narcotics. EI #3 said she just remembered seeing a card with 11 or 12 tablets on RI #224, from the backup pharmacy. EI #3 was asked what made her remember 11 or 12 tablets on RI #224. EI #3 said because the tablets were from back-up pharmacy. EI #3 was asked who did she count with on [DATE]. EI #3 said she would have counted off with EI #11. EI #3 was asked how many cards of narcotic did RI #224 have. EI #3 said she didn't recall .EI #3 was asked what was the procedure for counting narcotics at the end of the shift. EI #3 said the oncoming and off going nurse's would count the cards, bottles and they write down the total number and sign, then the oncoming nurse count the actual narcotic as the off going nurse called out the resident name, drug name, number of tabs and they must match, then both nurse's signed the control log sheet. EI #3 was asked where were these sheets kept. EI# 3 said in the front of the narcotic book. EI #3 was asked did she have any knowledge of the staff taking the resident's narcotics. EI #3 said she did not have any knowledge personally. The Alabama Department of Public Health Online Incident Reporting System received facility reports regarding the misappropriation of resident property on [DATE], [DATE] and [DATE]. As a result of these facility reports an onsite visit was conducted, in conjunction with the recertification survey. This deficiency is cited as a result of the investigations of complaint/report #AL 378, #AL 303 and #AL 296.",2020-09-01
56,ATHENS HEALTH AND REHABILITATION LLC,15016,611 WEST MARKET STREET,ATHENS,AL,35611,2019-08-29,658,D,1,1,39OM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of a facility policy titled Medication Orders, the facility failed to ensure Resident Identifier (RI) # 272 received additional [MEDICATION NAME] for three days, as ordered. This deficient practice affected RI #272, one of 25 sampled residents. Finding Include: A facility policy title: Medication Policies Prescriber Medication Orders dated 03/11 revealed the following, Policy Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Procedures 1. Elements of the Medication Order . (4) Time or frequency of administration. RI #272 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. The Physician order [REDACTED].#272, with an order start date of 4/24/19 and a stop date of 4/26/19. The order was to give [MEDICATION NAME] 20 MG (milligram) tablet- take one tablet everyday at noon for three days. On 8/29/19 at 5:52 p.m., the surveyor conducted an interview with Employee Identifier #3, Register Nurse (RN) Unit Manager. The surveyor asked EI #3 was RI #272 admitted to the facility on [MEDICATION NAME] 20 M[NAME] EI #3 stated yes, they were admitted on [MEDICATION NAME] 20 MG daily. The surveyor asked EI #3 when was the RI #272 discharged from the facility. EI #3 stated it looked like he/she was discharged on [DATE]. The surveyor asked EI #3 did he/she receive the [MEDICATION NAME] the entire time he/she was at the facility. EI #3 stated yes they (nursing) were signing off that he/she got the [MEDICATION NAME]. The surveyor asked EI #3 was there a new order for additional [MEDICATION NAME] 20 MG to be started on 4/24/19 and given for three days. EI #3 stated, give [MEDICATION NAME] 20 MG tablet by mouth at noon daily times three days in addition to morning dose. The surveyor asked EI #3 why was there a new order for the additional [MEDICATION NAME] 20 MG on 4/24/19 to be given one everyday at noon for three days. EI #3 stated she did not know, she guest he/she had some [MEDICAL CONDITION]. The survey asked EI #3 to look at the eMAR (electronic Medication Assessment Record) for (MONTH) 24th through the 26th. The surveyor then asked EI #3 did RI #272 receive [MEDICATION NAME] as ordered by the physician. EI #3 stated, he/she received two of the three dosages. The surveyor asked EI #3 how many dosages of [MEDICATION NAME] were missed. EI #3 stated, one. The surveyor asked EI #3 were the physician's orders [REDACTED]. EI #3 stated no. On 8/29/19 at 2:48 p.m., the surveyor conducted an interview with EI #7, RN Charge Nurse. The surveyor asked EI #7 did she remember RI #272. EI #7 stated yes she did remember the resident. The surveyor asked EI #7 what order did the physician give RI #272 for [MEDICATION NAME]. EI #7 stated, [MEDICATION NAME] 20 MG one table everyday at noon for three days. The surveyor asked EI #7 did she document the order. EI #7 stated it was her hand writing, so it had to be her. The surveyor asked EI #7 how many days was RI #7 given the new order for [MEDICATION NAME]. EI #7 stated it was two days, the 25th and the 26th of April. The surveyor asked EI #7 was the doctor's order followed for the order of [MEDICATION NAME]. EI #7 stated, not according to record. The surveyor asked EI #7 what was given according the records. EI #7 stated it looked like it was given two days. The surveyor asked EI #7 was that the new order given for [MEDICATION NAME] on 4/24/19. EI #7 stated, yes. The surveyor asked EI #7 was that RI #272's only order for [MEDICATION NAME]. EI #7 stated the resident had one other order for 8 am. The surveyor asked EI #7 what was that order. EI #7 stated it was for [MEDICATION NAME] 20 mg one tablet daily for [MEDICAL CONDITION]. The surveyor asked EI #7 why was that new order given. EI #7 stated she was going to assume it was for swelling because that was why they give [MEDICATION NAME]. The surveyor asked EI #7 had she ever observed any swelling on RI #272. EI #7 stated she remembered the resident having swelling in his/her feet and ankles. The surveyor asked EI #7 what were the results of new order of [MEDICATION NAME]. EI #7 stated the swelling went down in his/her feet and ankles. This citation is written as a result of the investigation of complaint/report #AL 292.",2020-09-01
57,ATHENS HEALTH AND REHABILITATION LLC,15016,611 WEST MARKET STREET,ATHENS,AL,35611,2019-08-29,695,D,0,1,39OM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, record review and review of a facility policy titled, Oxygen Administration , the facility failed to ensure oxygen masks and distilled water bottles were dated. This deficient practice had the potential to effect Resident Identifier (RI) #105, RI #274 and RI #275, three of three residents observed for oxygen therapy. Findings Include: A review of the facility policy titled, Oxygen Administration, effective date 12/08/2005, revealed, . Process: . 11. Cannula's and masks should be changed weekly . 14. O2 cannula/mask should be stored in a plastic bag when not in use. 1) RI #105 was re-admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. Physician Orders included an order, dated of 7/24/19, for O2 (Oxygen) at 2 L/M (Liter per Minutes) via NC (Nasal Cannula) as needed for SOB (Shortness of Breath). A care plan, dated 8/6/19, included, . Administer oxygen therapy as ordered. On 8/27/19 at 4:02 p.m., the surveyor observed RI #105's NC tubing and distilled water bottle on the oxygen concentrator were not dated. On 8/29/19 at 7:50 a.m., a second observation was made of the NC tubing and the distilled water bottle on the oxygen concentrator not dated 2) RI #274 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. A Physician's Orders included Oxygen at 2 L/M via nasal cannula, dated 8/22/19. A care plan included Administer oxygen therapy as ordered , dated 8/23/19. On 8/27/19 at 0:00 a.m., the surveyor observed RI #274's NC tubing and the distilled water bottle on the oxygen concentrator were not dated. On 8/27/19 at 3:27 p.m., during a second observation the surveyor observed that the NC tubing and distilled water on the oxygen concentrator were not dated. On 8/28/19 at 9:06 a.m., during a third observation the surveyor observed that the NC tubing and the distilled water bottle on the oxygen concentrator were not dated. 3) RI #275 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. A Physician's Order included O2 at 2 L/M prn (give as needed), with an order date of 8/24/19. A care plan included Administer oxygen therapy as ordered, dated 8/25/19. On 8/27/19 at 9:30 a.m., the surveyor observed RI #275's NC tubing was not dated while oxygen was being administered. On 8/28/19 at 9:13 a.m., during a second observation the surveyor observed NC tubing without a date. At this time the surveyor did observe the oxygen mask was dated 8/27/19 but was not in a bag/container. On 8/29/19 at 7:47 a.m., during a third observation the surveyor observed NC tubing without a date. On 8/29/19 at 2:06 p.m., during an interview with Employee Identifier (EI) #2, ADON (Assistance Director of Nursing) the surveyor asked her how often were the nasal cannula's changed. EI #2 said as needed and once per week. The surveyor asked EI #2 when should a date be placed on the NC tubing and the distilled water bottle on the concentrator. EI #2 stated when you change the NC tubing or the distilled water bottle. The surveyor asked EI #2 if there was no date on the NC tubing or distilled water bottle how would you know that they have been changed. EI #2 stated you would not know. The surveyor asked EI #2 what was the policy on dating the NC tubing and the distilled water bottle on the concentrator. EI #2 stated to change it weekly and the bottles are changed as needed if empty.",2020-09-01
58,ATHENS HEALTH AND REHABILITATION LLC,15016,611 WEST MARKET STREET,ATHENS,AL,35611,2019-12-19,656,D,1,0,QVJE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, a review of RI (Resident Identifier) #1's medical record, RI #1's Resident Incident Report, and the facility's policy titled, Person Centered Care Plans, the facility failed to ensure RI #1's care plan for a fall mat beside the bed was consistently implemented. This deficient practice affected RI #1, one of three sampled residents reviewed for falls. Findings Include: A review of a facility policy titled, Person Centered Care Plans, with an effective date of 8/15/18, documented: PURPOSE: Person centered plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals of the resident/guest, consistent with the resident/guest(s) rights. STANDARD: . According to federal regulations, the facility develops a comprehensive person centered plan of care for each resident/guest that includes measurable objectives and timetables to meet a resident/guest(s) medical, nursing and mental/psychosocial needs that are identified in the comprehensive assessment . PR[NAME]ESS: I.(f) .will ensure care plan intervention(s) are entered into Care Guide ADLs/Intervention in the electronic medical record that are considered outside of routine care. This will provide the CNA with individualized information needed to meet the resident's care needs. RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's Significant Change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 9/27/19, indicated RI #1 was cognitively intact, with a BIMS(Brief Interview for Mental Status) score of 14. RI #1's Resident Incident Report, prepared by EI (Employee Identifier) #1, RN (Registered Nurse), DON (Director of Nursing Services), indicated on 11/30/19 at 8:35 p.m., CNAs (Certified Nursing Assistants) EI #2 and E#3 called the nurse to the resident's room. The resident was lying on his/her left side, on the floor, beside the bed. RI #1's care plan titled, Potential for Falls: r/t (related to) bilateral AKA, lists the following interventions: Mat beside bed, with a start date of 9/10/19. On 12/11/19 at 9:30 a.m., an interview was conducted with EI #4, a CN[NAME] EI #4 was asked to tell the surveyor about the incident that happened on 11/30/19 involving RI #1. EI #4 said she was coming out of another resident's room and heard RI #1 hollering for help. EI #4 was asked what happened after hearing the resident. EI #4 said she, EI #2 and EI #3 all entered RI #1's room about the same time. EI #4 was asked what she saw when she entered the resident's room. EI #4 said RI #1 was on the floor. The resident told them he/she rolled over and fell . EI #4 was asked if she saw the fall mat in the room. EI #4 said no, after the fact she saw it in the closet because the closet door was open. EI #4 was asked if RI #1 was care planned for a fall mat. EI #4 said yes, it was on the care plan. On 12/11/19 at 12:31 p.m., an interview was conducted with EI #2, CN[NAME] EI #2 was asked if she found RI #1 on the floor on 11/30/19 at about 8:30 p.m. EI #2 said yes. EI #2 was asked what she saw when she entered RI #1's room. EI #2 said the resident was lying on his/her left side, on the floor facing the television. EI #2 was asked how she knew the resident was on the floor. EI # 2 said she heard the resident screaming for help. EI #2 was asked if she was the first person to enter the room. EI #2 said she and EI #3 entered the room at the same time. EI #2 was asked did she or EI #3 put RI #1's fall mat by RI #1's bed. EI #2 said no. EI #2 was asked who was responsible for putting the mat on the floor bedside. EI #2 said EI #3 and she were both responsible. EI #2 was asked was the care plan followed if the fall mat was not on the floor, bedside. EI #2 said no. On 12/11/19 at 3:15 p.m., an interview was conducted with EI #3, a CN[NAME] EI #3 was asked if he was assigned to care for RI #1 on 11/30/19 when the resident fell . EI #3 said he, EI #2 and EI #4, another CNA, were doing rooms together. EI #3 was asked where RI #1 was prior to the fall. EI #3 said the resident was in the wheelchair and he and EI #2 put the resident in the bed. EI #3 was asked if he or EI #2 put the fall mat on the floor by RI #1's bed. EI #3 said no, he did not put the fall mat on the floor. EI #3 was asked if he saw EI #2 put the fall mat on the floor. EI #3 said he did not know about the fall mat and when he was in the room he did not see a fall mat. EI #5 told him the resident needed to have the fall mat, after the fact, and pointed out that the fall mat was in the closet. EI #3 was asked if he saw the fall mat in the closet. EI #3 said yes, EI #5 pointed it out to him and he saw it in the closet. On 12/12/19 at 2:39 p.m., an interview was conducted with EI #1, Registered Nurse/ Director of Nursing. EI #1 was asked what the facility determined was the cause of the fall after the investigation. EI #1 said RI #1 was rolling himself/herself over to the left side and the resident kept rolling and hit the floor. EI #1 was asked if all of RI #1's interventions were in place when the resident had the fall. EI #1 said no, the mat was not in place. EI #1 was asked if the facility determined why the mat was not on the floor. EI #1 said the staff reported it was in the closet. EI #1 was asked if the staff followed the care plan. EI #1 said no, they did not. EI #1 was asked if the staff should have followed the care plan. EI #1 said yes. EI #1 was asked what the facility did to correct the problem. EI #1 said they had an emergency QA (Quality Assurance) meeting on 12/4/19 to put a plan in place. Education began on 12/1/19 to all staff about fall prevention and following interventions on care plans. The care plans for all residents at risk for falls were reviewed and updated. On 12/2/19 all care guides were reviewed for interventions. The RN Managers on each unit audited fall care plans and began monitoring them weekly. As the result of the staff not following RI #1's care plan intervention for a fall mat at bedside, the facility implemented the following action plan to ensure this deficient practice does not reoccur. 1. DON/Designee provided 1:1 in-service with the 2 CNAs on 12/1/2019 that failed to ensure RI #1's care plan intervention of a fall mat at bedside was implemented regarding fall prevention and following care plans. 2. DON/Designee will complete an audit of current active residents to ensure that current resident's care planned for fall mats are updated and implemented. Residents identified with a fall mat on their care plan will have a list in the CNA notebook at the nurse's station to communicate with CNAs. Any concerns noted will be addressed/corrected. The audit was completed by 12/2/19. 3. ADON (Assistant Director of Nursing)/Designee will in-service all nursing staff to ensure they are following and implementing residents care plans. Residents identified with a fall mat on their care plan will have a list in the CNA notebook at the nurse's station to communicate with CNAs. Any concerns noted will be addressed/corrected. These in-services were completed by 12/4/19. 4. DON/Designee will monitor residents' care plans that include fall mats 2 days a week x 4 weeks, then monthly thereafter for 3 months to ensure residents' care planed for fall mats are being utilized. Any concerns noted will be addressed/corrected, additional education will be provided and monitoring will continue. A copy of these checks will be kept in a binder in the Administrator's office.",2020-09-01
59,MERRY WOOD LODGE,15019,P O BOX 130,ELMORE,AL,36025,2019-03-02,600,J,1,0,KDKT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, review of Resident Identifier (RI) #1, RI #2's medical record, RI #3's medical record, the facility's policy titled OPS300 Abuse Prohibition and the facility's investigative file, the facility failed to ensure RI #2 and RI #3 were free from abuse perpetrated by RI #1, a resident who resides on the Homestead Memory Care (Dementia) Unit. On 1/25/2019 at 3:05 PM, RI #1 was ambulating in the hallway and bleeding from injuries to the right hand. There were three lacerations across the resident's knuckles. The trail of blood was followed and the staff observed RI #3 in his/her wheelchair bleeding from the lower lip, with a possible broken tooth. On 2/15/2019 at 7:45 PM, RI #1 and RI #2 were ambulating in the hallway towards each other, when RI #1 struck RI #2 with his/her right fist on RI #2's chin. The facility concluded RI #1, a resident identified as being physically aggressive toward others, struck RI #2 with no warning or provocation and physical abuse did occur. Beginning 2/15/2019 until 2/21/2019, RI #1 was to be provided 1:1 supervision/oversight during the resident's waking hours. However, during the evening shift on 2/20/2019, around supper time, the intervention of 1:1 supervision/oversight was not implemented and RI #1 was found by staff standing over RI #2, punching RI #2 in the head. This deficient practice affected RI #2 and RI #3, two of five sampled residents reviewed for resident to resident altercations; and placed RI #2 in immediate jeopardy for serious injury, harm or death. On 3/1/2019 at 3:40 PM, the facility's Administrator (Center Executive Director), Director of Nursing Service (Center Nurse Executive) and Director of Clinical Services were notified of the findings of immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation, F600. Findings include: The facility's policy titled, OPS300 Abuse Prohibition with a revision date of 7/1/2018, documented . POLICY Genesis HealthCare Centers will prohibit abuse . for all residents . Federal Definitions: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish . Instances of abuse of all patients, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish . Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Physical Abuse includes hitting, slapping, pinching, kicking, etc., . 1) RI #1 was admitted to the facility on [DATE]. RI #1 has a medical history to include [DIAGNOSES REDACTED]. RI #1's Quarterly Minimum Data Set (MDS) with an assessment reference date of 12/23/2018, indicated RI #1 was severely impaired in cognitive skills for daily decision making with a Brief Interview for Mental Status (BIMS) score of 2. For one to three days during this assessment period, RI #1 displayed physical and verbal behavior symptoms directed toward others. RI #2 was admitted to the facility on [DATE]. RI #2 has a medical history to include [DIAGNOSES REDACTED]. RI #2's Quarterly MDS with an assessment reference date of 11/28/2018, indicated RI #2 was severely impaired in cognitive skills for daily decision making, with a BIMS score of 4. For one to three days during this assessment period, RI #2 displayed verbal behavior symptoms directed toward others. On 2/15/2019, the facility reported an allegation of physical abuse to the Alabama State Survey Agency. According to the report, . (RI #1) and (RI #2) were ambulating in hallway toward one another. (RI #1) struck (RI #2) with (his/her) R (right) fist on (RI #2's) chin . Action(s) taken by the facility in response to the incident: . (RI #1) placed on 1:1 observation until referral to geri-psychiatric services . The facility's investigative summary dated 2/22/2019, documented . On (MONTH) 15, 2019, at approximately 7:45 PM, LPN (Licensed Practical Nurse) (EI (Employee Identifier) #4) was exiting Resident room [ROOM NUMBER] when she observed (RI #1) and (RI #2) walking towards one another. (EI #4) observed (RI #1) say something towards (RI #2), and then strike (RI #2) on (his/her) chin with a closed fist. The Nurse intervened to prevent further contact . Center Conclusions. RI #1 struck RI #2 with no warning or provocation . physical abuse did occur. From (MONTH) 15, 2019 until (MONTH) 21, 2019, RI #1 was provided 1:1 oversight during (his/her) waking hours. On (MONTH) 21, 2019, (he/she) was transferred to the acute geri-psychiatric setting . On 2/22/2019, anonymous callers reported to the Alabama State Survey Agency that RI #1 had repeatedly physically abused other residents on the Dementia Unit. According to the callers, earlier in the week during the second shift, RI #1 punched RI #2 in the chin. Then during the second shift on 2/20/2019, RI #1 was seen punching RI #2 in the face. The callers stated it was impossible for someone to watch RI #1 1:1 during the second shift because they were understaffed. During a telephone interview on 2/27/2019 at 9:31 AM, EI #5, a Certified Nursing Assistant (CNA) acknowledged she witnessed RI #1 hit RI #2 on 2/20/2019. When asked what she did observe, EI #5 stated as she was walking down hall she looked over in RI #2's room and saw RI #1 punching RI #2 in the head. When asked where RI #2 was, EI #5 said RI #2 was sitting on the bed and RI #1 was standing over RI #2 hitting him/her. According to EI #5, another CNA (EI #6) came over and asked what was going on. Also, EI #7, a CNA and EI #4, the LPN responded when EI #4 called for help. EI #5 stated she removed RI #1 from the room and asked the resident what was wrong. EI #5 replied, RI #1 told her that's ok I have taken care of the problem it has been going on 14 days. EI #5 was asked if she observed any injuries to either resident. EI #5 replied, she didn't see any injuries to RI #2 but RI #1's knuckles were red. EI #5 stated the nurse, EI #4, was made aware of what occurred. When asked if RI #1 was ever on 1:1, EI #5 stated before RI #1 hit RI #2 the second time (2/20/2019), RI #1 was on 1:1 for about a day. EI #5 stated she didn't know RI #1 was 1:1 when the second incident (2/20/2019) happened. During a telephone interview on 2/27/2019 at 10:36 AM, EI #7, a CNA acknowledged that she worked in the facility's locked (Dementia) unit during the second shift on 2/20/2019. When asked if she was familiar with RI #1, EI #7 said yes. EI #7 described RI #1 as being alert but very confused. EI #7 was asked, who was assigned to care for RI #1 during the second shift on 2/20/2019. EI #7 replied, EI #6 was. When asked if she witnessed RI #1 hitting RI #2 on 2/20/2019, EI #7 replied no. EI #7 was asked when she became aware of the altercation. EI #7 explained that the nurse, EI #4, had asked her to take a resident to the bathroom, when she heard EI #7 holler help or something to that nature. EI #7 stated she stopped what she was doing and went to RI #2's room; however, EI #6 was already there. According to EI #7, EI #5 said she went into the room and noticed RI #1 on top of RI #2 beating RI #2 with his/her fist. When asked if the nurse, EI #4, was notified of the altercation, EI #7 said yes. EI #7 stated the nurse told her that she had contacted the Director of Nursing Service (DNS), who stated to not do anything that she (DNS) would take care of it in the morning. EI #7 was asked if RI #1 was supposed to be on 1:1 on 2/20/2019. EI #7 replied, she wasn't sure. When asked if RI #1 had been on 1:1, EI #7 said yes she had heard that RI #1 was on 1:1 before, but EI #7 said she didn't think RI #1 was on 1:1 when she worked in the facility. EI #7 was asked how the CNAs would know if a resident was placed on 1:1 and she replied, I guess the nurse or supervisor would tell us. In an interview on 2/27/2019 at 3:45 PM, EI #6 acknowledged that she was assigned to care for RI #1 during the 2:00 PM to 10:00 PM shift on 2/20/2019. When asked if RI #1 was on 1:1 during her shift on 2/20/2019, EI #6 said no, the staff had been told that RI #1 was taken off 1:1. EI #6 explained that if RI #1 was 1:1, there would have been a paper with names on it to let the staff know what time they were assigned to watch RI #1, but when she came in there was no sheet to let the staff know the resident was on 1:1. When asked when RI #1's 1:1 was discontinued, EI #6 said she didn't know. EI #6 was asked if there was altercation between RI #1 and RI #2 on 2/20/2019. EI #6 answered, yes. When asked what happened, EI #6 said it was during supper time and she was in the middle of feeding another resident when EI #5 observed RI #2 sitting on the bed and RI #1 punching RI #2 in the face. EI #6 stated when she entered RI #2's room she could tell that RI #1 had hit RI #2 because RI #1's knuckles on both of his/her hands were red and RI #1 was sweating. Also, EI #6 stated the left side of RI #2's face looked bruised. According to EI #6, the nurse, EI #4, notified the DNS, who told her not to call RI #2's family, that the staff was going to be written up because they were not watching RI #1 and that she (DNS) would take care of things the next day. On 2/26/2019 at 3:49 PM, an interview was conducted with EI #4, the 2:00 PM to 10:00 PM (2nd shift) LPN assigned to work on the Homestead (Dementia) Unit. When asked if she was familiar with RI #1, EI #4 said yes. EI #4 stated RI #1 was a nice resident most of the time. According to EI #4, RI #1 did have a problem where he/she hit two residents. EI #4 explained on 12/16/2018, RI #1 knocked RI #3's tooth out. Then on 2/15/2019, EI #4 explained that she was coming out of room [ROOM NUMBER] and saw RI #1 hit RI #2 under the chin. EI #4 stated she yelled and got in between both residents. Afterwards, EI #4 stated she notified the Director of Nursing Service (DNS). When asked if she had been told to place RI #1 on 1:1, EI #4 said yes. When asked what 1:1 meant, EI #4 said that someone is with the resident at all times. EI #4 was asked if there was another altercation involving RI #1 on 2/20/2019. EI #4 said yes. EI #4 said she heard someone yelling and saw of the aides running up the hall. Later, EI #4 was told that RI #1 was beating RI #2 in the head. EI #4 said she called the DNS. According to EI #4, the DNS asked her what happened to the 1:1. EI #4 stated this was the first time she knew that 1:1 should have continued. EI #4 explained she didn't know the resident was still to be on 1:1. When asked if she documented the 2/20/2019 altercation, EI #4 said she did not. According to EI #4, the DNS told her not to document and that she would take care of it the next day. EI #4 stated the next day around 9:30 PM, RI #1 was picked up and taken to a geri-psychiatric setting. RI #1's Merry [NAME] Lodge Progress Notes written by EI #4, a LPN and dated 2/15/2019 at 9:48 PM, documented the following: . Note: A change in condition has been noted. The symptoms include: Other change in condition Hit another resident 02/15/2019 in the afternoon . A review of RI #1's medical record revealed no documentation regarding the 2/20/2019 incident in which RI #1 was observed punching another resident, RI #2, in the head. During an interview with EI #2, the Center Nurse Executive (CNE), also known as the DNS, on 2/28/2019 beginning at 9:36 AM, she was asked if she was familiar with RI #1. EI #2 said yes. When asked if RI #1 had behaviors, EI #2 said yes, the resident would become aggressive with staff during care and there were resident-to-resident altercations, where RI #1 would strike other residents. EI #2 was asked if resident-to-resident altercations were reportable to the State Survey Agency and she said yes. When asked what happened during the resident-to-resident altercation that occurred on 2/15/2019, EI #2 said the altercation involved RI #1 and RI #2. The nurse said both residents were ambulating in the hallway and RI #1 mumbled something and then hit RI #2 under the chin without provocation. When asked what interventions were implemented after this altercation, EI #2 said RI #1 was placed on 1:1 and there were no new interventions for RI #2 after the resident was assessed for injury. EI #2 was asked how long RI #1 was to be on 1:1. EI #2 replied, (RI #1) was supposed to be on 1:1 from 2/15/19 until (he/she) was D/C (discharged ) or other placement found or Geri-Psych arrangements could be made. When asked how staff was made aware that RI #1 was to be placed on 1:1, EI #2 said the night the nurse (EI #4) called her and she instructed the nurse to put someone with RI #1 1:1. Then the next morning, EI #2 stated she made assignments sheets and put them on the unit. When asked if RI #1 was 1:1 since 2/15/2019 until discharged , how it was possible that the resident was involved in another resident-to-resident altercation on 2/20/2019, EI #2 replied she didn't know. EI #2 was asked who was responsible to monitoring RI #1's 1:1 to ensure it was being done. EI #2 stated it was the responsibility of the Charge Nurses, but ultimately she was responsible. EI #2 stated there was a certain amount of trust she had with the Charge Nurses that they would do their job. When asked when she became aware of the resident-to-resident altercation that occurred on 2/20/2019, EI #2 stated it wasn't until the State Surveyor informed her last night (2/27/2019) and two people came into her office on yesterday asking what happened with RI #1. When asked who those two people were, EI #2 said she couldn't remember because people constantly come in and out of her office. EI #2 was asked what the staff should do when they observe a resident-to-resident altercation. EI #2 explained the staff are required to call the Abuse Coordinator, who is the facility's Administrator, document the altercation in the RMS (Risk Management System), complete a change of condition report, notify the physician and resident's family; and start to give instructions to the staff on duty. EI #2 acknowledged that none of this was done. When asked why the staff first notified her of the 2/15/2019 resident-to-resident altercation between RI #1 and RI #2, EI #2 said because she had the staff call her for everything. EI #2 stated after the staff calls her, she informs the Administrator. When asked should the 2/20/2019 resident-to-resident altercation involving RI #1 and RI #2 have been reported to the Alabama State Survey Agency, EI #2 said yes. EI #2 stated the general rule was to report the allegation within two hours. When asked why would the staff state she was notified of the 2/20/2019 altercation shortly after it occurred, and was told to not do anything and that she (EI #2) would take care of it in the morning, EI #2 replied, I don't know. I would never do that. EI #2 was asked if RI #1 was on 1:1 from 2/15/2019 until 2/21/2019, should there have been another physical resident-to-resident altercation. EI #2 replied, It would still be possible but less likely if (RI #1) was on 1:1. EI #2 explained that she only verbally informed the Charge Nurses to place RI #1 on 1:1. EI #2 stated she now realizes that she should have provided written education and had the staff to document that the intervention was being implemented. When asked who was ultimately responsible for ensuring 1:1 interventions were being implemented, EI #2 said she was. In an interview with EI #1, the Center Executive Director, also known as the Administrator on 2/28/2019 at 12:25 PM, he acknowledged that RI #1 was placed on 1:1 after the resident had been observed by staff to strike RI #2 under the chin on 2/15/2019 until other placement could be achieved; RI #1 was discharged from the facility on 2/21/2019. When asked should 1:1 have continued until RI #1 was discharged , EI #1 stated I thought it did but I now know that on 2/20/19, (RI #1) was observed in (RI #2's) room and was hitting (RI #2) in the face. According to EI #1, he was not made aware of this incident until 2/27/2019. 2) RI #1 was admitted to the facility on [DATE]. RI #1 has a medical history to include [DIAGNOSES REDACTED]. RI #1's Quarterly Minimum Data Set (MDS) with an assessment reference date of 12/23/2018, indicated RI #1 was severely impaired in cognitive skills for daily decision making with a Brief Interview for Mental Status (BIMS) score of 2. For one to three days during this assessment period, RI #1 displayed physical and verbal behavior symptoms directed toward others. RI #3 was admitted to the facility on [DATE]. RI #3 has a medical history to include [DIAGNOSES REDACTED]. RI #3's Quarterly MDS with an assessment reference date of 11/30/2018 indicated RI #3 was severely impaired in cognitive skills for daily decision making with a BIMS of 2. During this assessment period, RI #3 was not identified as displaying any behaviors. According to the facility's investigative file, on 1/25/2019 at 3:05 PM, RI #1 was ambulating in the hallway and bleeding from injuries to the right hand. There were three lacerations across the resident's knuckles. The trail of blood was followed and the staff observed RI #3 in his/her wheelchair bleeding from the lower lip, with a possible broken tooth. RI #1 denied any physical altercation. RI #3, who has a [DIAGNOSES REDACTED]. Law enforcement and the residents' families were notified. Both residents were sent to the local hospital for evaluation. RI #1 returned to the facility later that evening and RI #3 was admitted . On 1/28/2019, RI #1 was transferred to Geri-Psych at a local hospital. There were no witnesses to the incident. Both residents reside on the Memory Care Unit of the facility and they were roommates. The facility concluded that physical abuse occurred; however, they were unable to identify the aggressor or instigator. As the result of the incident, RI #3 was moved to another room when he/she returned to the facility. During an interview with EI #2, the Center Nurse Executive (CNE), also known as the Director of Nursing Service (DNS), on 2/28/2019 beginning at 9:36 AM, she was asked if RI #1 and RI #3 still shared a room when the 1/25/2019 incident occurred, EI #2 said yes because the facility could not determine whether a resident-to-resident altercation occurred on 12/26/2018 because there was no witnesses and the residents were unable to tell what happened. EI #2 explained that after the 1/25/2019, the same general interventions of close monitoring was in place since the facility treated this incident as a fall. According to EI #2, while there were no witnesses, one could tell something had occurred because RI #1 had blood on his/her knuckles and the trail of blood on the floor led to RI #3, who was found, in the shared room of both residents (RI #1 and RI #3), bleeding from the mouth. EI #2 stated after this incident RI #1 was placed on 1:1 until send out to a Geri-Psych setting. Then on 2/1/2019. the physician came in to assess RI #1 and determined that 1:1 was no longer needed. When asked how the facility monitored RI #1's aggressive behaviors after the 1/25/2019 incident, EI #2 said the same general interventions of monitoring. In an interview with RI #3 on 2/26/2019 at 11:03 AM, the resident was asked if he/she had ever been in a fight or had someone hit him/her while in the facility. RI #3 replied, We both hit each other. When asked why each resident hit each other, RI #3 stated the other resident had hit him/her. When asked who hit first, RI #3 replied the other resident hit him/her first. RI #3 was asked where was he/she hit and the resident replied, on my head. When RI #3 was asked if he/she was hurt, the resident stated no we just hit each other. ************************* On 03/02/19 at 7:15 p.m., the facility submitted an Allegation of Credible Compliance for F 600, which documented: F-600J-Freedom from Abuse and Neglect * Licensed Nurse discharged RI #1 to (local geri-psychiatric facility) on (MONTH) 21, 2019. * As of (MONTH) 1, 2019, staff were educated that the first contact for suspected abuse, neglect, misappropriation, or mistreatment is to be reported to the Center Executive Director, who is the Abuse Prevention Coordinator. * Interdisciplinary Team interviewed 7 of 7 residents deemed as interviewable on Homestead and/or with BIMs score ranging from 8-15 regarding Abuse and Resident to Resident altercations on the Homestead Unit on (MONTH) 2, 2019. No other resident to resident altercations were voiced by the residents. * Licensed Nurses completed skin assessment on 24 of 31 residents on Homestead identified with severe cognitive impairment to identify suspicion of Abuse and/or Neglect on the Homestead Unit. The skin assessments were completed (MONTH) 2, 2019. No concerns were identified. * The Nurse Practice Educator or designee educated 95 of 95 active employees from (MONTH) 27, through (MONTH) 2, (YEAR) (2019) on the Abuse Prohibition policy and procedure to include screening of potential hires; training of employees; prevention of occurrences; investigation of incidents and allegations; protection of residents during investigations; and reporting of incidents, investigations. Employees on leave of absence (FMLA), vacation, or PRN (as needed) staff will be re-educated prior to returning to duty. New hires are educated on Abuse Prohibition policy during orientation. * The Nurse Practice Educator or designee interviewed staff on (MONTH) 2, 2019, concerning knowledge of unreported instances of abuse, neglect, misappropriation, or mistreatment, to include resident-to-resident altercations. No concerns were identified. * Director of Clinical Operations educated the Center Executive Director and Center Nurse Executive on the Abuse Prohibition policy and procedure on (MONTH) 1, 2019. * Quality Assurance Performance Improvement (QAPI) meeting held on (MONTH) 1, 2019 with Interdisciplinary Team members and reviewed with the Medical Director (via phone) on the center's Abuse Prohibition policy. ************************* After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F600 was lowered to a D level on 3/2/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 156.",2020-09-01
60,MERRY WOOD LODGE,15019,P O BOX 130,ELMORE,AL,36025,2019-03-02,607,K,1,0,KDKT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, medical record review and review of the facility's policy titled OPS300 Abuse ProhibitionAbuse Policy, the facility failed to: 1) intervene and correct situations to prevent further abuse (Prevention); 2) ensure a Licensed Practical Nurse (LPN) and the Director of Nursing Service (DNS) reported an allegation of abuse to the Administrator, who serves as the Abuse Coordinator. Furthermore, this allegation of abuse was not reported timely to the State Survey Agency (Reporting); 3) protect Resident Identifier (RI) #2 and potentially other residents from abuse perpetrated by RI #1 (Protection); and 4) investigate an allegation of physical abuse (Investigation). On 4/19/2018 at approximately 4:45 PM, loud voices were heard in the hallway near room [ROOM NUMBER] on the Memory Care Unit. Staff responded and found RI #5 and RI #1 in a physical altercation; they were striking each other with their fists. On 11/23/2018 around 6:45 PM, RI #1 and RI #4 were found on the floor in RI #4's room. RI #4 said RI #1 entered his/her room, uninvited, used the bathroom and then tried to lay down in the empty bed. RI #4 tried to remove RI #1 and both residents fell to the floor. RI #1 sustained superficial scratches to the neck/chest, a skin tear to the right forearm and a torn t-shirt. On 12/16/2018 at approximately 6:55 PM, RI #1 and RI #3 were discovered on the floor in the residents' room. RI #3 had a cracked tooth and RI #1 had minor scratches on his/her right arm. On 1/25/2019 at 3:05 PM, RI #1 was ambulating in the hallway and bleeding from injuries to the right hand. There were three lacerations across the resident's knuckles. The trail of blood was followed and the staff observed RI #3 in his/her wheelchair bleeding from the lower lip, with a possible broken tooth. On 2/15/2019 at 7:45 PM, RI #1 and RI #2 were ambulating in the hallway towards each other, when RI #1 struck RI #2 with his/her right fist on RI #2's chin. The facility concluded RI #1 struck RI #2 with no warning or provocation and physical abuse did occur. During the 2:00 PM to 10:00 PM shift on 2/20/2019, around supper time, staff observed RI #1 standing over RI #2 in RI #2's room, punching RI #2 in the head. RI #1 was sweating and his/her knuckles were red. These deficient practices affected RI #2, RI #3, RI #4 and RI #5, four of five sampled residents reviewed for resident to resident altercations; and placed these residents in immediate jeopardy for serious injury, harm or death. These failures also had the potential to affect the remaining residents who resided on the facility's Homestead Memory Care (Dementia) Unit. On 3/1/2019 at 3:40 PM, the facility's Administrator (Center Executive Director), Director of Nursing Service (Center Nurse Executive) and Director of Clinical Services were notified of the findings of immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation, F607. Findings include: Refer to F600 The facility's policy titled OPS300 Abuse Prohibition with a revision date of 7/1/2018, documented . POLICY . The Center will implement an abuse prohibition program through the following: . * Prevention of occurrences; . * Investigation of incidents and allegations; * Protection of patients during investigations; and * Reporting of incidents, investigations, and Center response to the results of their investigations . PURPOSE To ensure that Center staff are doing all that is within their control to prevent occurrences of abuse . PR[NAME]ESS 1. The Center Executive Director, or designee, is responsible for operationalizing policies and procedures that prohibit abuse . PREVENTION The facility's policy titled OPS300 Abuse Prohibition with a revision date of 7/1/2018, documented . PR[NAME]ESS . 4. Actions to prevent abuse . will include: . 4.2 identifying, correcting, and intervening in situations in which abuse . is more likely to occur . Contained within the facility's investigation file were the following: On 4/19/2018 at approximately 4:45 PM, loud voices were heard in the hallway near room [ROOM NUMBER] on the Memory Care Unit. Staff responded and found RI #5 and RI #1 in a physical altercation; they were striking each other with their fists. Before staff could intervene, RI #5 fell to the floor and struck the back of his/her head against the floor or wall. Both residents sent to the local hospital for evaluation and returned back to the facility. Law enforcement, the residents' families and physician were notified. RI #5 was sent to acute Geri-Psych on 4/20/2018. RI #1 had a medical condition that delayed transfer to Geri-Psych; he/she remained on close monitoring by staff until sent. The facility concluded that physical abuse did occur; however, they could not determine the aggressor or the victim. As a result of the incident, the staff was provided education on proactive identification and response to possible resident aggression; position residents in common areas to respect personal space and freedom of movement. On 11/23/2018 around 6:45 PM, RI #1 and RI #4 were found on the floor in RI #4's room. RI #4 said RI #1 entered his/her room, uninvited, used the bathroom and then tried to lay down in the empty bed. RI #4 tried to remove RI #1 and both residents fell to the floor. RI #1 sustained superficial scratches to the neck/chest, a skin tear to the right forearm and a torn t-shirt. The facility concluded that no physical abuse occurred - the contact was deemed accidental. On 12/16/2018 at approximately 6:55 PM, RI #1 and RI #3 were discovered on the floor in the residents' room. RI #3 had a cracked tooth and RI #1 had minor scratches on his/her right arm. Neither resident could account for how they ended up on the floor or what happened. The staff did not hear or otherwise observe any interactions between the two residents. RI #1 had been walking around the Memory Care (Dementia) Unit and RI #3 was in the bed, with the bed in the lowest position. RI #3 was sent to the local hospital for evaluation. The facility was unable to substantiate that abuse occurred or who the victim or aggressor was. On 1/25/2019 at 3:05 PM, RI #1 was ambulating in the hallway and bleeding from injuries to the right hand. There were three lacerations across the resident's knuckles. The trail of blood was followed and the staff observed RI #3 in his/her wheelchair bleeding from the lower lip, with a possible broken tooth. RI #1 denied any physical altercation. RI #3, who has a [DIAGNOSES REDACTED]. Law enforcement and the residents' families were notified. Both residents were sent to the local hospital for evaluation. RI #1 returned to the facility later that evening and RI #3 was admitted . On 1/28/2019, RI #1 was transferred to Geri-Psych at a local hospital. There were no witnesses to the incident. Both residents reside on the Memory Care Unit of the facility and they were roommates. The facility concluded that physical abuse occurred; however, they were unable to identify the aggressor or instigator. As the result of the incident, RI #3 was moved to another room when he/she returned to the facility. On 2/15/2019 at 7:45 PM, RI #1 and RI #2 were ambulating in the hallway towards each other, when RI #1 struck RI #2 with his/her right fist on RI #2's chin. This allegation was reported to the SA on 2/15/2019 at 8:50 PM. The five-day report concluded RI #1 struck RI #2 with no warning or provocation. While neither resident was injured, physical abuse did occur. Beginning 2/15/2019 until 2/21/2019, RI #1 was provided 1:1 oversight during the resident's waking hours. On 2/21/2019, RI #1 was transferred to an acute Geri-psychiatric facility. During the 2:00 PM to 10:00 PM shift on 2/20/2019, around supper time, staff observed RI #1 standing over RI #2 in RI #2's room, punching RI #2 in the head. RI #1 was sweating and his/her knuckles were red. According to the Licensed Practical Nurse (LPN), she informed the DNS; however, she was told to not document anything that she, the DNS, would take care of everything in the morning. On 2/21/2019, RI #1 was discharged to a local Geri-Psychiatric setting. During an interview with EI #2, the Center Nurse Executive (CNE), also known as the Director of Nursing Service (DNS), on 2/28/2019 beginning at 9:36 AM, she was asked what intervention(s) was put in place after the 4/19/2018 incident. EI #2 said there were none for that time period. When asked what intervention(s) were put in place after the 11/23/2018 incident, EI #2 said RI #1 was assisted to his/her room and gotten ready for bed. EI #2 was asked about the 12/26/2018 incident. According to EI #2, after the incident, RI #3 was sent to the hospital and when RI #3 returned to the facility the resident was placed in a room by himself/herself for the remainder of the night to avoid any further confrontations. When asked if RI #1 and RI #3 still shared a room when the 1/25/2019 incident occurred, EI #2 said yes because the facility could not determine whether a resident-to-resident altercation occurred on 12/26/2018 because there was no witnesses and the residents were unable to tell what happened. EI #2 explained that after the 1/25/2019, the same general interventions of close monitoring was in place since the facility treated this incident as a fall. According to EI #2, while there were no witnesses, one could tell something had occurred because RI #1 had blood on his/her knuckles and the trail of blood on the floor led to RI #3, who was found, in the shared room of both residents (RI #1 and RI #3), bleeding from the mouth. EI #2 stated after this incident RI #1 was placed on 1:1 until send out to a Geri-Psych setting. Then on 2/1/2019. the physician came in to assess RI #1 and determined that 1:1 was no longer needed. When asked how the facility monitored RI #1's aggressive behaviors after the 1/25/2019 incident, EI #2 said the same general interventions of monitoring. EI #2 was asked what interventions were put in place after the 2/15/2019 incident between RI #1 and RI #2. She explained there were no interventions for RI #2 other than the assessment for injury; however, RI #1 was placed on 1:1 until discharge or other placement could be found or Geri-Psych arrangements could be made. When asked how staff was made aware that RI #1 was to be placed on 1:1, EI #2 said the night the nurse (EI #4) called her and she instructed the nurse to put someone with RI #1 1:1. Then the next morning, EI #2 stated she made assignments sheets and put them on the unit. EI #2 explained that she only verbally informed the Charge Nurses to place RI #1 on 1:1. EI #2 stated she now realizes that she should have provided written education and had the staff to document that the intervention was being implemented. When asked who was ultimately responsible for ensuring 1:1 interventions were being implemented, EI #2 said she was. During a telephone interview on 2/27/2019 at 9:31 AM, EI #5, a Certified Nursing Assistant (CNA) acknowledged she witnessed RI #1 hit RI #2 on 2/20/2019. EI #5 stated she didn't know RI #1 was 1:1 when the second incident on 2/20/2019 happened. During a telephone interview on 2/27/2019 at 10:36 AM, EI #7, a CNA acknowledged that she worked in the facility's locked (Dementia) unit during the second shift on 2/20/2019. When asked if RI #1 had been on 1:1, EI #7 said yes she had heard that RI #1 was on 1:1 before, but she didn't think RI #1 was on 1:1 when she worked in the facility. EI #7 was asked how the CNAs would know if a resident was placed on 1:1 and she replied, I guess the nurse or supervisor would tell us. In an interview on 2/27/2019 at 3:45 PM, EI #6 acknowledged that she was assigned to care for RI #1 during the 2:00 PM to 10:00 PM shift on 2/20/2019. When asked if RI #1 was on 1:1 during her shift on 2/20/2019, EI #6 said no, the staff had been told that RI #1 was taken off 1:1. EI #6 explained that if RI #1 was 1:1, there would have been a paper with names on to let the staff know what time they were assigned to watch RI #1, but when she came in there was no sheet to let the staff know the resident was on 1:1. When asked when RI #1's 1:1 was discontinued, EI #6 said she didn't know. On 2/26/2019 at 3:49 PM, an interview was conducted with EI #4, the 2:00 PM to 10:00 PM (2nd shift) LPN assigned to work on the Homestead (Dementia) Unit. EI #4 was asked if there was another altercation involving RI #1 on 2/20/2019. EI #4 said yes. EI #4 said she heard someone yelling and saw of the aides running up the hall. Later EI #4 was told that RI #1 was beating RI #2 in the head. EI #4 said she called the DNS. According to EI #4, the DNS asked her what happened to the 1:1. EI #4 stated this was the first time she knew that 1:1 should have continued. EI #4 explained she didn't know the resident was still to be on 1:1. In an interview with EI #1, the Center Executive Director, also known as the Administrator on 2/28/2019 at 12:25 PM, he was asked what intervention(s) were put in place after the 4/19/2018 incident. EI #1 said RI #5 was discharged to the hospital for evaluation and subsequently sent to a mental health setting, while RI #1 was placed on close monitoring while out of bed. When asked what was done to deter the 11/23/2018 from reoccurrence, EI #1 said RI #5 was assigned to another room outside of the Memory Care Unit. According to EI #1, the 12/16/2018 incident between RI #1 and RI #3 was treated as a fall. When asked what interventions were put in place after the 2/15/2019 resident-to-resident altercation between RI #1 and RI #2, EI #1 said RI #1 was placed on 1:1 until discharged from the facility on 2/21/2019. When asked should 1:1 have continued until RI #1 was discharged , EI #1 stated I thought it did but I now know that on 2/20/19, (RI #1) was observed in (RI #2's) room and was hitting (RI #2) in the face. According to EI #1, he was not made aware of this incident until 2/27/2019. RI #1's care plan titled Resident/patient exhibits, or has the potential to exhibit physical behaviors such . Physical aggression toward others . initiated 2/6/2018 had the following interventions: redirect and offer rest periods if resident becomes agitated was initiated on 5/4/2018 by EI #2; a medication review by the psychiatrist was initiated on 11/24/2018 by EI #2; a roommate change was initiated on 1/30/2019 by EI #12, a LPN; supervision to and from activity was initiated on 1/30/2019 by EI #12; medication adjustment was created on 2/5/2019 by EI #11, a Registered Nurse (RN); an attempt to keep RI #1 in populated areas and provide redirection as needed was initiated on 1/30/2019 by EI #12 and revised on 2/7/2019 by EI #2; 1:1 supervision with escalation of behaviors as needed was initiated on 2/7/2019 by EI #2; an activity board for 1:1 entertainment was initiated on 2/7/2019 by EI #2; monthly psychiatrist visits were initiated on 2/7/2019 by EI #2; and 1:1 supervision was initiated on 2/18/2019 by EI #11, a RN. REPORTING/RESPONSE The facility's policy titled OPS300 Abuse Prohibition with a revision date of 7/1/2018, documented . PR[NAME]ESS . 5.1 Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. 5.1.1 The notified supervisor will report the suspected abuse immediately to the Center Executive Director (CED) or designee and other officials in accordance with state law. 6. Upon receiving information concerning a report of suspected or alleged abuse . the CED (Center Executive Director) or designee will perform the following: 6.1 Enter allegation into the Risk Management System (RMS). 6.2 Report allegations involving abuse (physical, verbal, sexual, mental) not later than two hours after the allegation is made . 6.5 Notify local law enforcement, Licensing Boards and Registries, and other agencies as required . On 2/26/2019 at 3:49 PM, an interview was conducted with EI #4, the 2:00 PM to 10:00 PM (2nd shift) LPN assigned to work on the Homestead (Dementia) Unit. EI #4 was asked if there was another altercation involving RI #1 on 2/20/2019. EI #4 said yes. EI #4 said she heard someone yelling and saw of the aides running up the hall. Later EI #4 was told that RI #1 was beating RI #2 in the head. EI #4 said she called the DNS. According to EI #4, the DNS told her not to document and that she would take care of it the next day. EI #4 stated the next day around 9:30 PM, RI #1 was picked up and taken to a geri-psychiatric setting. During an interview with EI #2, the Center Nurse Executive (CNE), also known as the Director of Nursing Service (DNS), on 2/28/2019 beginning at 9:36 AM, she was asked if resident-to-resident altercations were reportable to the Alabama State Survey Agency. EI #2 said yes. EI #2 was asked what the staff should do when they observe a resident-to-resident altercation. EI #2 explained the staff are required to call the Abuse Coordinator, who is the facility's Administrator, document the altercation in the RMS (Risk Management System), complete a change of condition report, notify the physician and resident's family; and start to give instructions to the staff on duty. EI #2 acknowledged that none of this was done. When asked why the staff first notified her of the 2/15/2019 resident-to-resident altercation between RI #1 and RI #2, EI #2 said because she had the staff call her for everything. EI #2 stated after the staff calls her, she informs the Administrator. When asked if the 2/20/2019 resident-to-resident altercation involving RI #1 and RI #2 should have been reported to the Alabama State Survey Agency, EI #2 said yes. EI #2 stated the general rule was to report the allegations within two hours. When asked why would the staff stated she was notified of the 2/20/2019 altercation shortly after it occurred and was told to not do anything that she (EI #2) would take care of it in the morning, EI #2 replied I don't know. I would never do that. When asked when she became aware of the resident-to-resident altercation that occurred on 2/20/2019, EI #2 stated it wasn't until the State Surveyor informed her last night (2/27/2019) and two people came into her office on yesterday asking what happened with RI #1. When asked who those two people were, EI #2 said she couldn't remember because people constantly come in and out of her office. In an interview with EI #1, the Center Executive Director, also known as the Administrator on 2/28/2019 at 12:25 PM, he acknowledged the 2/20/2019 incident that occurred between RI #1 and RI #2 was a reportable incident to the Alabama State Survey Agency. According to EI #1, he was not made aware of the incident until 2/27/2019 by a representative from the Alabama State Survey Agency. When asked what he expected the staff to do when they became aware of the incident, EI #1 said the Charge Nurse should have notified the Abuse Coordinator, the physician, and the Supervisor; the notifications of all parties should have been documented in the residents' medical records; an assessment should have completed and documented for both residents; an incident report should have been completed; and the provision of 1:1 supervision for RI #1 should have been reinforced. EI #1 acknowledged none of this was done. On 2/27/2019 at 6:46 PM, the Alabama State Survey Agency received a facility reported allegation of physical abuse involving RI #1 and RI #2 that occurred on 2/20/2019 at 7:00 PM. INVESTIGATION The facility's policy titled OPS300 Abuse Prohibition with a revision date of 7/1/2018, documented . PR[NAME]ESS . 6.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on: 6.7.1 whether abuse or neglect occurred and to what extent; 6.7.2 clinical examination for signs of injuries, if indicated; 6.7.3 causative factors; and 6.7.4 interventions to prevent further injury. 6.8 The investigation will be thoroughly documented within RMS. Ensure that documentation of witnessed interviews is included. 6.8.1 Conduct interviews using the Alleged Perpetrator/Victim Interview Record and Witness Interview Record. 6.8.2 Enter a summary of the interviews into RMS. 6.8.3 Interview forms will be kept confidential in a file in the administrative office . During an interview with EI #2, the Center Nurse Executive (CNE), also known as the Director of Nursing Service (DNS), on 2/28/2019 beginning at 9:36 AM, was asked what the staff should do when they observe a resident-to-resident altercation. EI #2 explained the staff are required to call the Abuse Coordinator, who is the facility's Administrator, document the altercation in the RMS (Risk Management System), complete a change of condition report, notify the physician and resident's family; and start to give instructions to the staff on duty. EI #2 acknowledged that none of this was done. In an interview with EI #1, the Center Executive Director, also known as the Administrator on 2/28/2019 at 12:25 PM, was asked what he expected the staff to do when they became aware of the incident, EI #1 said the Charge Nurse should have notified the Abuse Coordinator, the physician, and the Supervisor; the notifications of all parties should have been documented in the residents' medical records; an assessment should have completed and documented for both residents; an incident report should have been completed; and the provision of 1:1 supervision for RI #1 should have been reinforced. EI #1 acknowledged none of this was done. According to the facility's investigative summary submitted to the Alabama State Survey dated 3/5/2019, documented . Allegation Summary. On (MONTH) 27, 2019, in the course of an Abbreviated Complaint Surrey by the Alabama Department of Public Health, the Center Executive Director (Abuse Prevention Coordinator) was notified that during the 2-10p shift of (MONTH) 20, 2019, an alleged resident-to-resident altercation occurred between (RI #1) and (RI #2) . Center Findings . * There was no notification to sponsors/physicians; documentation in the record; or, investigation of the allegation until (MONTH) 27, 2019 . PROTECTION The facility's policy titled OPS300 Abuse Prohibition with a revision date of 7/1/2018, documented . 5.2 If the suspected abuse is resident-to-resident, the resident who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed. 5.2.1 The Center will provide adequate supervision when the risk of resident-to-resident altercation is suspected. 5.2.2 The Center is responsible for identifying residents who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation. 5.2.3 The family and physician will be notified . PR[NAME]ESS . 7. The Center will protect patients from further harm during an investigation. 7.1 Provide the patient with a safe environment by identifying persons with whom he/she feels safe and conditions that would feel safe. 7.2 Assign a representative from Social Services or a designee to monitor the patient's feelings concerning the incident, as well as the patient's involvement in the investigation . During an interview with EI #2, the Center Nurse Executive (CNE), also known as the DNS, on 2/28/2019 beginning at 9:36 AM, was asked what interventions were implemented after this altercation, EI #2 said RI #1 was placed on 1:1. EI #2 was asked how long RI #1 was to be on 1:1. EI #2 replied, (RI #1) was supposed to be on 1:1 from 2/15/19 until (he/she) was D/C (discharged ) or other placement found or Geri-Psych arrangements could be made. When asked if RI #1 was 1:1 since 2/15/2019 until discharged , how it was possible that the resident was involved in another resident-to-resident altercation on 2/20/2019, EI #2 replied she didn't know. EI #2 was asked who was responsible to monitoring RI #1's 1:1 to ensure it was being done. EI #2 stated it was the responsibility of the Charge Nurses, but ultimately she was responsible. EI #2 was asked if RI #1 was on 1:1 from 2/15/2019 until 2/21/2019, should there have been another physical resident-to-resident altercation. EI #2 replied, It would still be possible but less likely if (RI #1) was on 1:1. EI #2 explained that she only verbally informed the Charge Nurses to place RI #1 on 1:1. EI #2 stated she now realizes that she should have provided written education and had the staff to document that the intervention was being implemented. When asked who was ultimately responsible for ensuring 1:1 interventions were being implemented, EI #2 said she was. In an interview with EI #1, the Center Executive Director, also known as the Administrator on 2/28/2019 at 12:25 PM, he acknowledged that RI #1 was placed on 1:1 after the resident had been observed by staff to strike RI #2 under the chin on 2/15/2019 until other placement could be achieved; RI #1 was discharged from the facility on 2/21/2019. When asked should 1:1 have continued until RI #1 was discharged , EI #1 stated I thought it did but I now know that on 2/20/19, (RI #1) was observed in (RI #2's) room and was hitting (RI #2) in the face. According to the facility's investigative summary submitted to the Alabama State Survey dated 3/5/2019, documented . Allegation Summary. On (MONTH) 27, 2019, in the course of an Abbreviated Complaint Surrey by the Alabama Department of Public Health, the Center Executive Director (Abuse Prevention Coordinator) was notified that during the 2-10p shift of (MONTH) 20, 2019, an alleged resident-to-resident altercation occurred between (RI #1) and (RI #2) . Center Findings . * The 1:1 supervision of (RI #1) by Center staff, put into place on (MONTH) 15, 2019, was not maintained through (RI #1's) discharge date of (MONTH) 21, 2019, enabling (RI #1) to strike (RI #2) on (MONTH) 20, 2019 . ************************* On 3/2/2019 at 7:15 PM, the facility submitted an Allegation of Credible Compliance for F607, which documented: F-607 J-Development and implementation of written Abuse Prohibition policies. Licensed Nurse discharged RI #1 to Baptist Senior Care Unit on (MONTH) 21, 2019. As of (MONTH) 1, 2019, staff were educated that the first contact for suspected abuse, neglect, misappropriation, or mistreatment is to be reported to the Center Executive Director, who is the Abuse Prevention Coordinator. The Nurse Practice Educator or designee educated 95 of 95 active employees from (MONTH) 27, through (MONTH) 2, (YEAR) on the implementation of Abuse Prohibition policy and procedure to include protection of the resident. Employees on leave of absence (FMLA), vacation, or PRN staff will be re-educated prior to returning to duty. New hires are educated on the Abuse Prohibition policy during orientation. The Nurse Practice Educator or designee interviewed staff on (MONTH) 2, 2019, concerning knowledge of unreported instances of abuse, neglect, misappropriation, or mistreatment, to include resident-to-resident altercations. No concerns were identified. Director of Clinical Operations educated the Center Executive Director and Center Nurse Executive on the implementation of Abuse Prohibition policy and procedure to include protection of residents on (MONTH) 1, 2019. Quality Assurance Performance Improvement (QAPI) meeting held on (MONTH) 1, 2019 with Interdisciplinary Team members and reviewed with the Medical Director (via phone) on the center's Abuse Prohibition policy. ************************* After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F607 was lowered to a [NAME] level on 3/2/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 156.",2020-09-01
61,MERRY WOOD LODGE,15019,P O BOX 130,ELMORE,AL,36025,2019-03-02,609,J,1,0,KDKT11,"> Based on interviews and review of the facility's policy titled OPS Abuse Prohibition the Licensed Practical Nurse (LPN) and the Director of Nursing Service (DNS) failed to report an allegation of physical abuse to the Administrator, who serves as the Abuse Coordinator. Furthermore, this allegation of abuse was not timely reported to the Alabama State Survey Agency. During the 2:00 PM to 10:00 PM shift on 2/20/2019, around supper time, staff observed Resident Identifier (RI) #1 standing over RI #2 in RI #2's room, punching RI #2 in the head. RI #1 was sweating and his/her knuckles were red. According to the LPN, she informed the DNS; however, she was told to not document anything that she, the DNS, would take care of everything in the morning. On 2/27/2019 at 6:46 PM, the Alabama State Survey Agency received a facility reported allegation of physical abuse involving RI #1 and RI #2 that occurred on 2/20/2019 at 7:00 PM. This deficient practice affected RI #1 and RI #2, two of five sampled residents reviewed for abuse; and placed these residents in immediate jeopardy for serious injury, harm or death. This failure also had the potential to affect the remaining residents who resided on the facility's Homestead Memory Care (Dementia) Unit. On 3/1/2019 at 3:40 PM, the facility's Administrator (Center Executive Director), Director of Nursing Service (Center Nurse Executive) and Director of Clinical Services were notified of the findings of immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation, F609. Findings include: Refer to F600 The facility's policy titled OPS300 Abuse Prohibition with a revision date of 7/1/2018, documented . PR[NAME]ESS 1. The Center Executive Director, or designee, is responsible for operationalizing policies and procedures that prohibit abuse . 5.1 Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. 5.1.1 The notified supervisor will report the suspected abuse immediately to the Center Executive Director (CED) or designee and other officials in accordance with state law. 6. Upon receiving information concerning a report of suspected or alleged abuse . the CED (Center Executive Director) or designee will perform the following: 6.1 Enter allegation into the Risk Management System (RMS). 6.2 Report allegations involving abuse (physical, verbal, sexual, mental) not later than two hours after the allegation is made . 6.5 Notify local law enforcement, Licensing Boards and Registries, and other agencies as required . On 2/26/2019 at 3:49 PM, an interview was conducted with EI #4, the 2:00 PM to 10:00 PM (2nd shift) Licensed Practical Nurse (LPN) assigned to work on the Homestead (Dementia) Unit. EI #4 was asked if there was another altercation involving RI #1 on 2/20/2019. EI #4 said yes. EI #4 said she heard someone yelling and saw of the aides running up the hall. Later, EI #4 was told that RI #1 was beating RI #2 in the head. EI #4 said she called the DNS. According to EI #4, the DNS told her not to document and that she would take care of it the next day. EI #4 stated the next day around 9:30 PM, RI #1 was picked up and taken to a geri-psychiatric setting. During an interview with EI #2, the Center Nurse Executive (CNE), also known as the Director of Nursing Service (DNS), on 2/28/2019 beginning at 9:36 AM, she was asked if resident-to-resident altercations were reportable to the Alabama State Survey Agency. EI #2 said yes. EI #2 was asked what the staff should do when they observe a resident-to-resident altercation. EI #2 explained the staff are required to call the Abuse Coordinator, who is the facility's Administrator, document the altercation in the RMS (Risk Management System), complete a change of condition report, notify the physician and resident's family; and start to give instructions to the staff on duty. EI #2 acknowledged that none of this was done. When asked why the staff first notified her of the 2/15/2019 resident-to-resident altercation between RI #1 and RI #2, EI #2 said because she had the staff call her for everything. EI #2 stated after the staff calls her, she informs the Administrator. When asked if the 2/20/2019 resident-to-resident altercation involving RI #1 and RI #2 should have been reported to the Alabama State Survey Agency, EI #2 said yes. EI #2 stated the general rule was to report the allegations within two hours. When asked why would the staff state she was notified of the 2/20/2019 altercation shortly after it occurred and was told to not do anything and that she (EI #2) would take care of it in the morning, EI #2 replied I don't know. I would never do that. When asked when she became aware of the resident-to-resident altercation that occurred on 2/20/2019, EI #2 stated it wasn't until the State Surveyor informed her last night (2/27/2019) and two people came into her office on yesterday asking what happened with RI #1. When asked who those two people were, EI #2 said she couldn't remember because people constantly come in and out of her office. In an interview with EI #1, the Center Executive Director, also known as the Administrator on 2/28/2019 at 12:25 PM, he acknowledged the 2/20/2019 incident that occurred between RI #1 and RI #2 was a reportable incident to the Alabama State Survey Agency. According to EI #1, he was not made aware of the incident until 2/27/2019 by a representative from the Alabama State Survey Agency. When asked what he expected the staff to do when they became aware of the incident, EI #1 said the Charge Nurse should have notified the Abuse Coordinator, the physician, and the Supervisor; the notifications of all parties should have been documented in the residents' medical records; an assessment should have completed and documented for both residents; an incident report should have been completed; and the provision of 1:1 supervision for RI #1 should have been reinforced. EI #1 acknowledged none of this was done. On 2/27/2019 at 6:46 PM, the Alabama State Survey Agency received a facility reported allegation of physical abuse involving RI #1 and RI #2 that occurred on 2/20/2019 at 7:00 PM. ************************* On 3/2/2019 at 7:15 PM, the facility submitted an Allegation of Credible Compliance for F609, which documented: F-609 J- Reporting of Alleged Violations Licensed Nurse discharged RI #1 to Baptist Senior Care Unit on (MONTH) 21, 2019. As of (MONTH) 1, 2019, staff were educated that the first contact for suspected abuse, neglect, misappropriation, or mistreatment is to be reported to the Center Executive Director, who is the Abuse Prevention Coordinator. Center Executive Director submitted an online report with the State Agency on (MONTH) 27, 2019 related to the resident to resident altercation occurrence on (MONTH) 20, 2019. The Nurse Practice Educator or designee educated 95 of 95 active employees from (MONTH) 27, through (MONTH) 2, (YEAR) on the Abuse Prohibition policy and procedure to include reporting of incidents. Employees on leave of absence (FMLA), vacation, or PRN staff will be re-educated prior to returning to duty. New hires are educated on the Abuse Prohibition policy related to reporting during orientation. The Nurse Practice Educator or designee interviewed staff on (MONTH) 2, 2019, concerning knowledge of unreported instances of abuse, neglect, misappropriation, or mistreatment, to include resident-to-resident altercations. No concerns were identified. Director of Clinical Operations educated the Center Executive Director and Center Nurse Executive on the Abuse Prohibition policy and procedure to reporting of incidents on (MONTH) 1, 2019. Quality Assurance Performance Improvement (QAPI) meeting held on (MONTH) 1, 2019 with Interdisciplinary Team members and reviewed with the Medical Director (via phone) on the center's Abuse Prohibition policy. ************************* After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F609 was lowered to a D level on 3/2/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 156.",2020-09-01
62,MERRY WOOD LODGE,15019,P O BOX 130,ELMORE,AL,36025,2019-03-02,610,J,1,0,KDKT11,"> Based on interviews and review of the facility's policy titled OPS300 Abuse Prohibition, the facility failed to immedately investigate an allegation of physical abuse perpetrated by Resident Identifier (RI) #1, a cognitively impaired resident who resides on the facility's Homestead Memory Care (Dementia) Unit. During the 2:00 PM to 10:00 PM shift on 2/20/2019, around supper time, staff observed Resident Identifier (RI) #1 standing over RI #2 in RI #2's room, punching RI #2 in the head. RI #1 was sweating and his/her knuckles were red. According to the Licensed Practical Nurse (LPN), she informed the Director of Nursing Service (DNS); however, she was told to not document anything that the DNS, would take care of everything in the morning. There was no documentation or investigation of this allegation of physical abuse until 2/27/2019. This deficient practice affected RI #1 and RI #2, two of five sampled residents reviewed for abuse; and placed these residents in immediate jeopardy for serious injury, harm or death. This failure also had the potential to affect the remaining residents who reside on the facility's Homestead Memory Care (Dementia) Unit. On 3/1/2019 at 3:40 PM, the facility's Administrator (Center Executive Director), Director of Nursing Service (Center Nurse Executive) and Director of Clinical Services were notified of the findings of immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation, F610. Findings include: Refer to F600 The facility's policy titled OPS300 Abuse Prohibition with a revision date of 7/1/2018, documented . PR[NAME]ESS 1. The Center Executive Director, or designee, is responsible for operationalizing policies and procedures that prohibit abuse . 6.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on: 6.7.1 whether abuse or neglect occurred and to what extent; 6.7.2 clinical examination for signs of injuries, if indicated; 6.7.3 causative factors; and 6.7.4 interventions to prevent further injury. 6.8 The investigation will be thoroughly documented within RMS (Risk Management System). Ensure that documentation of witnessed interviews is included. 6.8.1 Conduct interviews using the Alleged Perpetrator/Victim Interview Record and Witness Interview Record. 6.8.2 Enter a summary of the interviews into RMS. 6.8.3 Interview forms will be kept confidential in a file in the administrative office . In an interview with Employee Identifier (EI) #1, the Center Executive Director, also known as the Administrator, on 2/28/2019 at 12:25 PM, he was asked what he expected the staff to do when they became aware of the incident. EI #1 said the Charge Nurse should have notified the Abuse Coordinator, the physician, and the Supervisor; the notifications of all parties should have been documented in the residents' medical records; an assessment should have been completed and documented for both residents; an incident report should have been completed; and the provision of 1:1 supervision for RI #1 should have been reinforced. EI #1 acknowledged none of this was done. According to the facility's investigative summary submitted to the Alabama State Survey Agency dated 3/5/2019, documented . Allegation Summary. On (MONTH) 27, 2019, in the course of an Abbreviated Complaint Surrey by the Alabama Department of Public Health, the Center Executive Director (Abuse Prevention Coordinator) was notified that during the 2-10p shift of (MONTH) 20, 2019, an alleged resident-to-resident altercation occurred between (RI #1) and (RI #2) . Center Findings . * There was no . documentation in the record; or, investigation of the allegation until (MONTH) 27, 2019 . ************************* On 3/2/2019 at 7:15 PM, the facility submitted an Allegation of Credible Compliance for F610, which documented: F-610 J-Investigate/Prevent/Correct Alleged Violation Licensed Nurse discharged RI #1 to Baptist Senior Care Unit on (MONTH) 21, 2019. As of (MONTH) 1, 2019, staff were educated that the first contact for suspected abuse, neglect, misappropriation, or mistreatment is to be reported to the Center Executive Director, who is the Abuse Prevention Coordinator. Center Executive Director initiated an investigation on (MONTH) 27, 2019 related to the resident to resident altercation on (MONTH) 20, 2019. The Nurse Practice Educator or designee educated 95 of 95 active employees from (MONTH) 27, through (MONTH) 2, (YEAR) on the Abuse Prohibition policy and procedure to include investigation of incidents. Employees on leave of absence (FMLA), vacation, or PRN staff will be re-educated prior to returning to duty. New hires are educated on the Abuse Prohibition policy related to investigating incidents during orientation. The Nurse Practice Educator or designee interviewed staff on (MONTH) 2, 2019, concerning knowledge of unreported instances of abuse, neglect, misappropriation, or mistreatment, to include resident-to-resident altercations. No concerns were identified. Director of Clinical Operations educated the Center Executive Director and Center Nurse Executive on the Abuse Prohibition policy and procedure to include investigation of incidents on (MONTH) 1, 2019. Quality Assurance Performance Improvement (QAPI) meeting held on (MONTH) 1, 2019 with Interdisciplinary Team members and reviewed with the Medical Director (via phone) on the center's Abuse Prohibition policy. ************************* After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F610 was lowered to a D level on 3/2/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 156.",2020-09-01
63,MERRY WOOD LODGE,15019,P O BOX 130,ELMORE,AL,36025,2019-03-02,725,K,1,0,KDKT11,"> Based on interviews, review of the facility's policy titled OPS138 Staffing/Center Plan, the Facility's Assessment Tool, the facility's daily census, staffing and assignment report, the facility failed to ensure sufficient staff was assigned to work during the evening shift on 2/20/2019 on the Homestead Memory Care (Dementia) Unit. The facility had determined the staffing needs for the evening shift was one direct care staff per nine residents. The daily census for the Dementia Unit for 2/20/2019 was 34, which indicated two direct care staff were assigned to care for 11 residents and one direct care staff was assigned to care for 12 residents. During the evening shift on 2/20/2019 around supper time, Resident Identifier (RI) #1, a resident identified as being physically aggressive towards others, was found by staff standing over RI #2, punching RI #2 in the head. RI #1 had previously been identified to physically abuse RI #2 on 2/15/2019. After this physical altercation, RI #1 was to be placed on 1:1 until discharge from the facility. This intervention was not implemented, thus RI #1 was found again physically abusing RI #2, five days later. This deficient practice affected RI #2, one of five sampled residents reviewed for resident to resident altercations; and placed RI #2 in immediate jeopardy for serious injury, harm or death. This failure also had the potential to affect the remaining residents who resided on the facility's Homestead Memory Care (Dementia) Unit. On 3/1/2019 at 3:40 PM, the Administrator, Director of Nursing Service and Director of Clinical Operations were notified of the findings of immediate jeopardy in the area of Nursing Services, F725. Findings include: The facility's policy titled OPS138 Staffing/Center Plan with a revision date of 9/1/2013, documented POLICY Genesis HealthCare Centers will provide qualified and appropriate staffing levels to meet the needs of the patient population. The staffing plan will include all shifts, seven days per week. PURPOSE To assure that appropriate staff levels are scheduled and maintained. PR[NAME]ESS . 4. The Center maintains appropriate staff levels, with qualified personnel, 24 hours/day, seven days/week on each shift to assure that patients are safe and their needs are met. Inquiries concerning nursing staffing should be referred to the Nursing Director . The facility's FACILITY ASSESSMENT TOOL for the Homestead Memory Care Unit dated (MONTH) (YEAR), indicated the direct care staff for the evening shift was one staff per nine residents. On 2/22/2019, anonymous callers reported to the Alabama State Survey Agency that RI #1 had repeatedly physically abused other residents on the Dementia Unit. According to the callers, earlier in the week during the second shift, RI #1 punched RI #2 in the chin. Then during the second shift on 2/20/2019, RI #1 was seen punching RI #2 in the face. The callers stated it was impossible for someone to watch RI #1 1:1 during the second shift because they were understaffed. The Merry [NAME] Lodge Daily Census for 2/20/2019 indicated there were a total of 34 residents who resided on the Homestead Memory Care (Dementia) Unit. The daily staffing sheet for 2/20/2019 indicated there were a total of three Certified Nursing Assistants (CNAs) scheduled to work during the evening shift, 2:00 PM to 10:00 PM; however, one CNA was listed as working 2:30 PM to 8:30 PM. The CNAs were listed as Employee Identifier (EI) #5, EI #6 and EI #7. The Homestead Assignment Sheet for the evening shift on 2/20/2019 revealed EI #5, CNA was assigned to care for 11 residents; EI #6 was assigned to care for 12 residents; and EI #7 was assigned to care for 11 residents. In a telephone interview on 2/27/2019 at 9:31 PM, EI #5, a CNA, said normally three CNAs work the unit. EI #5 said three was not an adequate number of CNAs to work the unit and she had told the person who does scheduling (EI #10, the Staffing Coordinator) that four CNAs were needed. During a telephone interview on 2/27/2019 at 10:36 AM, EI #7, a CNA confirmed there were three CNAs working the Homestead Unit on 2/20/2019. EI #7 stated it was very seldom four CNAs worked the unit. In an interview on 3/1/2019 at 9:34 AM, EI #10, the Staffing Coordinator was asked how the Dementia unit was staffed. EI #10 stated normally there are three CNAs, one male and two female CNAs. EI #10 explained that the male CNA only cared for the eight male residents that resided on the unit, leaving the other two female CNAs to split the other female residents. When asked about the 2/20/2019 incident, EI #10 stated the census on the Homestead Unit was 34 residents. When asked how many staff were scheduled, EI #10 said three females. EI #10 was asked how many residents each staff member had. EI #10 replied that two CNAs had 11 and one CNA had 12. When asked what the facility's assessment indicated the staffing pattern should be for evening shift on the Homestead Unit, EI #10 said one CNA per nine residents. When asked if staffing levels during the evening shift on 2/20/2019 reflected the assessed needs of the unit per the Facility's Assessment, EI #10 said no ma'am. EI #10 was asked if anyone had reported staffing concerns to her related to the facility's Dementia unit. EI #10 said EI #5 had. On 3/1/2019 at 10:25 AM, an interview was conducted with EI #2, the Center Nurse Executive (CNE), also known as the Director of Nursing Service (DNS). EI #2 said she was involved in staffing by helping to make sure the facility had adequate staff for each unit. EI #2 said according to the Daily Staff sheet for the Homestead Unit on 2/20/2019, the census was 34. EI #2 confirmed there were three CNAs scheduled to work and two of the CNAs were assigned to care for 11 residents and one CNA was assigned to care for 12 residents. EI #2 said according to the Facility's Assessment, the ratio was to be one staff to care for nine residents. EI #2 said that staff on that shift did not meet the Facility Assessment's guideline. During an interview with EI #1, the Center Executive Director, also known as the Administrator, on 3/1/2019 at 3:10 PM, he confirmed the facility's Assessment ratio of one staff to care for nine residents was not followed on 2/20/2019, on the Homestead unit for the 2:00 PM to 10:00 PM shift. ************************* On 3/2/2019 at 7:15 PM, the facility submitted an Allegation of Credible Compliance for F725, which documented: F-725 J- Nursing Services; sufficient nursing staff On (MONTH) 20, 2019, on the 2-10 pm shift 3 Certified Nursing Assistants were assigned to the Homestead Unit. Effective (MONTH) 1, 2019, the first and second shifts in the Homestead memory care unit were scheduled with four (4) CNAs. This level of staffing of the Homestead unit will be continued until revised per the Facility Assessment. On (MONTH) 1, 2019, the Nurse Practice Educator validated the employees assigned to the Homestead Unit met the Dementia training education requirements. On (MONTH) 1, 2019, the Center Executive Director (CED) educated the Center Nurse Executive (CNE) and Center Scheduler on ensuring proper direct-care staffing is available on the Homestead unit, per the Facility Assessment. ************************* After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F725 was lowered to a [NAME] level on 3/2/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 156.",2020-09-01
64,MERRY WOOD LODGE,15019,P O BOX 130,ELMORE,AL,36025,2019-03-02,835,K,1,0,KDKT11,"> Based on interview and review of the Center Nurse Executive's job description, the Center Nurse Executive (CNE), also known as the Director of Nursing Service (DNS), responsible for the overall operations associated with direct patient care, failed to ensure staff was provided written education on when and how to provide 1:1 supervision of Resident Identifier (RI) #1 and further failed to ensure the 1:1 supervision was implemented from 2/15/2019 until 2/21/2019. On 2/15/2019 at 7:45 PM, RI #1 and RI #2 were ambulating in the hallway towards each other, when RI #1 struck RI #2 with his/her right fist on RI #2's chin. The facility concluded RI #1 struck RI #2 with no warning or provocation. Beginning 2/15/2019 until 2/21/2019, RI #1 was to be provided 1:1 supervision/oversight during the resident's waking hours. However, during the 2:00 PM to 10:00 PM shift on 2/20/2019, around supper time, staff observed RI #1 standing over RI #2 in RI #2's room, punching RI #2 in the head. RI #1 was sweating and his/her knuckles were red. According to the Licensed Practical Nurse (LPN), she informed the DNS and was told to not document anything that she, the DNS, would take care of everything in the morning. On 2/21/2019, RI #1 was discharged to a local Geri-Psychiatric setting. During interview on 2/28/2019, Employee Identifier (EI) #2 stated she now realized that she should have provided written education and had the staff to document that the 1:1 supervision intervention was being implemented for RI #1. This deficient practice affected RI #2, one of five sampled residents reviewed for resident to resident altercations; and placed RI #2 in immediate jeopardy for serious injury, harm or death. This failure also had the potential to affect the remaining residents who resided on the facility's Homestead Memory Care (Dementia) Unit. On 3/1/2019 at 3:40 PM, the facility's Administrator (Center Executive Director), Director of Nursing Service (Center Nurse Executive) and Director of Clinical Services were notified of the findings of immediate jeopardy in the area of Administration, F835. Findings include: Refer to F600 and F607 The GENESIS HEALTHCARE JOB DESCRIPTION: CENTERS for the position titled Center Nurse Executive with a revision date of 6/16/2017, documented . POSITION SUMMARY: The Center Nurse Executive leads the Center clinical team to fulfill the organization's mission, vision and value. This position has overall accountability for providing leadership, direction, and administration of day-to-day operations associated with direct patient care activities . RESPONSIBILITIES/ACCOUNTABILITIES: . Clinical Leadership: . 2.8 Monitors nursing care to ensure positive clinical outcome . During an interview with EI #2, the Center Nurse Executive (CNE), also known as the DNS, on 2/28/2019 beginning at 9:36 AM, she was asked if she was familiar with RI #1. EI #2 said yes. When asked if RI #1 had behaviors, EI #2 said yes, the resident would become aggressive with staff during care and there were resident-to-resident altercations, where RI #1 would strike other residents. When asked what happened during the resident-to-resident altercation that occurred on 2/15/2019, EI #2 said the altercation involved RI #1 and RI #2. The nurse said both residents were ambulating in the hallway and RI #1 mumbled something and then hit RI #2 under the chin without provocation. When asked what interventions were implemented after this altercation, EI #2 said RI #1 was placed on 1:1 and there were no new interventions for RI #2 after the resident was assessed for injury. EI #2 was asked how long RI #1 was to be on 1:1. EI #2 replied, (RI #1) was supposed to be on 1:1 from 2/15/19 until (he/she) was D/C (discharged ) or other placement found or Geri-Psych arrangements could be made. When asked how staff was made aware that RI #1 was to be placed on 1:1, EI #2 said the night the nurse (EI #4) called her and she instructed the nurse to put someone with RI #1 1:1. Then the next morning, EI #2 stated she made assignment sheets and put them on the unit. When asked if RI #1 was 1:1 since 2/15/2019 until discharged , how it was possible that the resident was involved in another resident-to-resident altercation on 2/20/2019, EI #2 replied she didn't know. EI #2 was asked who was responsible to monitoring RI #1's 1:1 to ensure it was being done. EI #2 stated it was the responsibility of the Charge Nurses, but ultimately she was responsible. EI #2 stated there was a certain amount of trust she had with the Charge Nurses that they would do their job. When asked when she became aware of the resident-to-resident altercation that occurred on 2/20/2019, EI #2 stated it wasn't until the State Surveyor informed her last night (2/27/2019) and two people came into her office on yesterday asking what happened with RI #1. When asked who those two people were, EI #2 said she couldn't remember because people constantly come in and out of her office. EI #2 was asked what the staff should do when they observe a resident-to-resident altercation. EI #2 explained the staff are required to call the Abuse Coordinator, who is the facility's Administrator, document the altercation in the RMS (Risk Management System), complete a change of condition report, notify the physician and resident's family; and start to give instructions to the staff on duty. EI #2 acknowledged that none of this was done. When asked why the staff first notified her of the 2/15/2019 resident-to-resident altercation between RI #1 and RI #2, EI #2 said because she had the staff call her for everything. EI #2 stated after the staff calls her, she informs the Administrator. When asked should the 2/20/2019 resident-to-resident altercation involving RI #1 and RI #2 have been reported to the Alabama State Survey Agency, EI #2 said yes. EI #2 stated the general rule was to report the allegation within two hours. When asked why would the staff state she was notified of the 2/20/2019 altercation shortly after it occurred, and was told to not do anything and that she (EI #2) would take care of it in the morning, EI #2 replied, I don't know. I would never do that. EI #2 was asked if RI #1 was on 1:1 from 2/15/2019 until 2/21/2019, should there have been another physical resident-to-resident altercation. EI #2 replied, It would still be possible but less likely if (RI #1) was on 1:1. EI #2 explained that she only verbally informed the Charge Nurses to place RI #1 on 1:1. EI #2 stated she now realizes that she should have provided written education and had the staff to document that the intervention was being implemented. When asked who was ultimately responsible for ensuring 1:1 interventions were being implemented, EI #2 said she was. ************************* On 3/2/2019 at 7:15 PM, the facility submitted an Allegation of Credible Compliance for F 835, which documented: F-835 J- Administration On (MONTH) 1, 2019, the Director of Clinical Operations educated the Center Executive Director and Center Nurse Executive on ensuring residents are free from Abuse and Neglect, implementing Abuse policies and procedures, reporting alleged violations timely, and investigating alleged incidents. As of (MONTH) 1, 2019, staff were educated that the first contact for suspected abuse, neglect, misappropriation, or mistreatment is to be the Center Executive Director, who is the Abuse Prevention Coordinator. On (MONTH) 1, 2019, Director of Clinical Operations reviewed allegations of Abuse and Neglect in the last 30 days to ensure written Abuse Prohibition policies and procedures were implemented and allegations were reported timely, thoroughly investigated, and residents were protected. No concerns were identified. On (MONTH) 1, 2019, the Director of Clinical Operations hosted a Quality Assurance Performance Improvement meeting with selected Department Managers and reviewed the Abuse Prohibition policy and procedure to ensure residents are free from Abuse and Neglect, Abuse policies and procedures are implemented, alleged violations are reported timely, and thoroughly investigated. ************************** After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F835 was lowered to a [NAME] level on 3/2/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 156.",2020-09-01
65,MERRY WOOD LODGE,15019,P O BOX 130,ELMORE,AL,36025,2020-03-03,580,D,1,1,LZCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of a facility policy titled Change in Condition: Notification of the facility failed to contact Resident Identifier (RI) # 24's resident representative when his/her diet was changed to pureed in August 2019. This affected 1 of 20 sampled residents. Findings Include: A review of policy titled Change in Condition: Notification of, with an effective date of 11/28/16, documented: .A Center must immediately inform the patient's Health Care Decision Maker (HCDM) where there is:.A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment. RI # 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI # 24 also had a [DIAGNOSES REDACTED]. A review of RI # 24's diet orders documented the following: 8/13/19.Resident's diet downgraded to pureed due to coughing when eating. Resident appearing at times to have trouble swallowing regular tray. Speech Therapy (ST) was alerted and to see resident. On 03/02/20 at 2:53 p.m. the Surveyor reviewed RI # 24's medical record. A Speech Therapy Initial Evaluation for therapy dates 8/2/19 through 8/31/19 documented the following: . Patient/Caregiver Education = Family/caregiver expressed understanding of evaluation and agreement with goals and treatment plan; Does patient/family agree w/ (with) Diet Recommendation? = Yes. On 3/2/20 at 9:38 a.m. an interview was completed with Employee Identifier (EI) # 3, Speech Therapist. EI # 3 stated she had RI # 24 on her case load on and off in 2019 for swallowing and cognitive problems. EI # 3 was asked what type of diet she recommended for RI # 24. EI # 3 stated she recommended a pureed diet in August of 2019 and RI #24 received that diet after the recommendation. A follow-up telephone interview was completed with EI # 3, Speech Therapist, on 3/2/20 at 2:47 p.m. EI # 3 was asked if she contacted RI # 24's family when he/she went on pureed diet in August. EI # 3 stated no. EI # 3 further stated she had a conversation with RI # 24's daughter but did not call her about the diet change. EI # 3 was asked what the statement on the Speech Therapy Initial Evaluation for therapy dates 8/2/19 through 8/31/19 meant when it documented the Family/Caregiver expressed understanding of the evaluation and agreement with goals and treatment plan to include the diet recommendation. EI # 3 stated it meant she spoke with the facility about the resident's diet, not the family. EI # 3 was asked if she normally called family regarding a diet change. EI # 3 stated no. An interview was completed with EI # 4, Registered Nurse (RN), on 3/3/20 at 9:35 a.m. EI # 4 was asked if nursing staff called RI # 24's daughter when his/her diet was downgraded in August of 2019. EI # 4 stated there was a note about downgrading the diet on 8/13/19, but it was not documented the daughter was called and informed. EI # 4 further stated it should be documented. EI # 4 was asked what was the potential negative outcome of not notifying family of changes. EI # 4 stated the family not knowing about the change.",2020-09-01
66,MERRY WOOD LODGE,15019,P O BOX 130,ELMORE,AL,36025,2020-03-03,732,C,1,1,LZCS11,"> Based on observation and interview, the facility failed to ensure Nurse Staffing information was posted on Saturday, 2/29/20, when the survey team entered the building. This was observed on 2/29/20 and had the potential to affect all 92 residents residing in the facility, as well as family and visitors in the facility. Findings include: On 2/29/20 at 1:00 p.m., the survey team entered the facility and observed the Nurse Staffing information posted; the posting was dated for the previous day, 2/28/20, instead of for the current date and shift. On 3/03/20 at 3:17 p.m., Employee Identifier (EI) # 6, Licensed Practical Nurse (LPN), was interviewed. EI # 6 was asked who was responsible for ensuring Nurse Staffing information was posted daily on the weekends. EI # 6 said the first hall nurse was responsible. EI # 6 further stated she had been the nurse working on the 1st hall on 2/29/20. When asked if she had posted the Nurse Staffing information that day, EI # 6 said no, she forgot. EI # 6 said she should have posted the staffing information for 2/29/20 that morning. EI # 6 was asked the purpose of posting the Nurse Staffing information daily in the facility. EI # 6 said it should be posted because it shows the public how many people are working, shows the number of employees in the building, as well as the number of residents.",2020-09-01
67,MERRY WOOD LODGE,15019,P O BOX 130,ELMORE,AL,36025,2020-03-03,756,D,1,1,LZCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interviews, review of the consultant pharmacist's February 2020 Medication Regimen Review reports, and review of policies titled 9.1 Medication Regimen Review and 3.8 [MEDICAL CONDITION] Medication Use, the facility failed to ensure the consultant pharmacist identified concerns during the February 2020 medication review with Resident Identifier (RI) #24's [MEDICATION NAME], an antipsychotic medication, that was ordered on [DATE] without adequate justification for use. This affected RI #24, one of six sampled residents reviewed for unnecessary medications. Findings include: Review of the policy titled 9.1 Medication Regimen Review, dated 11/28/16, revealed the following: .PROCEDURE . 1.1 The drug regimen of each skilled nursing facility resident must be reviewed at least once a month by a licensed pharmacist. Review of the policy titled 3.8 [MEDICAL CONDITION] Medication Use, revised 11/28/16, revealed the following: POLICY This Policy 3.8 sets forth procedures relating to [MEDICAL CONDITION] medication use. DEFINITION A [MEDICAL CONDITION] drug is any medication that affects brain activities associated with mental processes and behavior, PROCEDURE . 8. Antipsychotic medications used to treat Behavioral or Psychological Symptoms of Dementia (BPSD) must be clinically indicated, be supported by an adequate rationale for use, and may not be used for a behavior with an unidentified cause. RI #24 was originally admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of hospital records indicated RI #24 was transferred to the hospital on [DATE] due to complaints of chest pain, where he/she remained overnight until readmitted to the facility on [DATE]. Review of RI #24's current physician orders [REDACTED]. However, review of RI #24's order history, revealed RI #24 had not received [MEDICATION NAME] since the order was previously discontinued on 11/02/2018. Further, review of RI #24's current comprehensive care plans revealed no care plan for any behaviors. Review of the Pharmacy Consultation Reports indicated monthly Medication Regimen Reviews had been conducted from 2/16-2/18/20. RI #24's recommendation reports indicated the pharmacist had not identified a concern with the order for [MEDICATION NAME]. On 3/03/20 at 3:18 PM, a consultant Pharmacist (Pharmacist #1) was asked to explain the [MEDICAL CONDITION] Medication Use policy and the reference to a clinically indicated use and rationale. Pharmacist #1 stated there were a number of psychiatric disorders, as well as behaviors with intention for harm, that would warrant the use of antipsychotic medication. Pharmacist #1 stated he had not reviewed the policy in some time and did not realize it was so vague. When asked about [MEDICATION NAME] and whether Dementia or Alzheimer's would be an appropriate [DIAGNOSES REDACTED].#1 said no, unless there were documented behaviors or other diagnoses. Pharmacist #1 stated he filled orders for medications, but Pharmacist #2 was in the facility each month to conduct the medication reviews. Pharmacist #2 was interviewed on 3/03/2020 at 3:35 PM. Pharmacist #2 stated RI #24 had been prescribed [MEDICATION NAME] once daily for Alzheimer's. When asked what types of [DIAGNOSES REDACTED].#2 said dementia with associated behaviors. He further stated Alzheimer's was not the best [DIAGNOSES REDACTED].#24's [MEDICATION NAME]. After reviewing the information he had available on RI #24, Pharmacist #2 said he had notes indicating he had recommended a dose reduction on RI #24's [MEDICATION NAME] on 7/2/18 and it had been completely discontinued as of his note on 12/4/18. Pharmacist #2 also indicated another pharmacist (Pharmacist #3) made a note on 1/28/2020 that indicated RI #24 was receiving [MEDICATION NAME] 25 mg daily for Dementia. When asked what was an adequate rationale for use of an antipsychotic, Pharmacist #2 said [MEDICAL CONDITION]'s, [MEDICAL CONDITION], or Dementia with behaviors; He further stated dementia without behaviors would not be a reason to warrant use of [MEDICATION NAME]. As far as making a recommendation regarding the rationale and [DIAGNOSES REDACTED].#24's [MEDICATION NAME], Pharmacist #2 said he must have missed it when doing his February 2020 review.",2020-09-01
68,MERRY WOOD LODGE,15019,P O BOX 130,ELMORE,AL,36025,2020-03-03,758,D,1,1,LZCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interviews, and review of the facility's policy titled [MEDICAL CONDITION] Medication Use, the facility failed to ensure Resident Identifier (RI) #24 was not given [MEDICATION NAME], an antipsychotic medication, without a [DIAGNOSES REDACTED]. This affected RI #24, one of six sampled residents reviewed for unnecessary medications. Findings include: Review of the policy titled 3.8 [MEDICAL CONDITION] Medication Use, revised 11/28/2016, revealed the following: POLICY This Policy 3.8 sets forth procedures relating to [MEDICAL CONDITION] medication use. DEFINITION A [MEDICAL CONDITION] drug is any medication that affects brain activities associated with mental processes and behavior, PROCEDURE . 3. [MEDICAL CONDITION] medications may be used to address behaviors only if non-drug approaches and interventions were attempted prior to their use. . 8. Antipsychotic medications used to treat Behavioral or Psychological Symptoms of Dementia (BPSD) must be clinically indicated, be supported by an adequate rationale for use, and may not be used for a behavior with an unidentified cause. RI #24 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of hospital records indicated RI #24 was transferred to the hospital on [DATE] due to complaints of chest pain, where he/she remained overnight until readmitted to the facility on [DATE]. Review of RI #24's current physician orders [REDACTED]. However, review of RI #24's order history, revealed RI #24 had not received [MEDICATION NAME] since the order was discontinued on 11/02/18. Further, review of RI #24's current comprehensive care plans revealed no care plan addressing any behaviors. RI #24's January and February 2020 Medication Administration Record [REDACTED]. A telephone interview was completed on 3/2/20 at 3:37 p.m. with Employee Identifier (EI) # 7, Nurse Practitioner. EI # 7 was asked if she was aware RI #24 was readmitted to the facility on [DATE] with [MEDICATION NAME]. EI # 8 stated she was not aware and that EI # 8, the Medical Director, would be the one to sign off on it. An interview was completed on 3/3/20 at 2:48 p.m. with EI # 5, Licensed Practical Nurse (LPN), the nurse that processed RI #24's readmission on [DATE]. When asked how familiar she was with RI #24, EI # 5 said she was very familiar because RI #24 was her resident from the time of his/her original admission. EI # 5 said she was the nurse at the time RI #24 was readmitted on [DATE] and she had completed the admission. When asked what her responsibility was as the admitting nurse for reviewing the resident's medications. EI # 5 said she was responsible for making sure the orders were transcribed into the computer. When asked what the rationale for use of the [MEDICATION NAME] was when RI #24 returned from the hospital, EI # 5 said she had no idea, nor did she know if RI #24 was receiving the [MEDICATION NAME] before going to the hospital. EI # 5 further stated [MEDICATION NAME] was an antipsychotic medication. When asked why she had not questioned the order for the [MEDICATION NAME], EI # 5 said she did not know; she just assumed RI #24 was taking it before going out to the hospital. EI # 5 said she should have compared the medication orders RI #24 was taking prior to going to the hospital with the ones listed after RI #24's return, but she had not done that. When asked why it was important to have a rationale for the use of an antipsychotic medication, EI # 5 said the resident should not be on the medication if he/she does not need it. EI # 5 was then asked if RI #24 had any sort of behaviors prior to going out to the hospital, EI # 5 said RI #24 would sometimes have some anxiety, but they would get RI #24 and his/her roommate together and RI #24 would calm down. When asked if RI #24 displayed any behaviors after returning from the hospital, EI # 5 said he/she would complain of chest pain. When asked about the facility's policy regarding the use of antipsychotic medications, EI # 5 said anyone with orders for an antipsychotic should have a behavior sheet on their Medication Administration Record [REDACTED]. During a follow-up interview with EI # 5 on 3/03/20 at 5:24 p.m., EI # 5 stated she faxed the Medical Director, EI # 7, a copy of RI #24's admission orders [REDACTED]. EI # 5 said she had called the Medical Director and discussed pain medication orders but she did not recall asking about the [MEDICATION NAME]; she had just assumed RI #24 had been receiving it before going to the hospital. On 3/03/20 at 3:18 p.m., a consultant Pharmacist (Pharmacist #1) was asked to explain the Use of [MEDICAL CONDITION] Medications policy and the reference to a clinically indicated use and rationale. Pharmacist #1 stated there were a number of psychiatric disorders, as well as behaviors with intention for harm, that would warrant the use of antipsychotic medication. Pharmacist #1 stated he had not reviewed the policy in some time and did not realize it was so vague. When asked about [MEDICATION NAME] and whether Dementia or Alzheimer's would be an appropriate [DIAGNOSES REDACTED].#1 said no, unless there were documented behaviors or other diagnoses. Pharmacist #1 stated he filled medication orders, but Pharmacist #2 was in the facility each month to review medication orders. Pharmacist #2 was interviewed on 3/03/20 at 3:35 p.m. Pharmacist #2 stated RI #24 had been prescribed [MEDICATION NAME] once daily for Alzheimer's. When asked what types of [DIAGNOSES REDACTED].#2 said dementia with associated behaviors. He further stated Alzheimer's was not the best [DIAGNOSES REDACTED].#24's [MEDICATION NAME]. After reviewing the information he had available on RI #24, Pharmacist #2 said he had notes indicating he had recommended a dose reduction on RI #24's [MEDICATION NAME] on 7/2/18 and it had been completely discontinued as of his note on 12/4/18. Pharmacist #2 also indicated another pharmacist (Pharmacist #3) made a note on 1/28/20 that indicated RI #24 was receiving [MEDICATION NAME] 25 mg daily for Dementia. When asked what was an adequate rationale for use of an antipsychotic, Pharmacist #2 said [MEDICAL CONDITION]'s, [MEDICAL CONDITION], or Dementia with behaviors; He further stated dementia without behaviors would not be a reason to warrant use of [MEDICATION NAME]. Pharmacist #2 also said he had met with the facility in February to discuss psychoactive medications, but he was not sure if RI #24's [MEDICATION NAME] had been discussed. He indicated EI # 9, the Director of Nursing (DON), would have the notes from that meeting. Pharmacist #3, that completed the admission medication review, was interviewed on 3/03/20 at 4:28 p.m. When asked what types of [DIAGNOSES REDACTED].#3 stated any psychiatric [DIAGNOSES REDACTED]. When questioned whether RI #24 should have received [MEDICATION NAME] after coming back from the hospital (after it had been discontinued since 2018), Pharmacist #3 said if there was no indication of harmful behaviors, she would hope the facility would consider getting the resident off of the medication. Pharmacist #3 further stated there have to be behaviors and dose reductions when residents are on antipsychotic medications. On 3/3/20 at 4:15 p.m., EI # 9, the DON, was asked about the February meeting referenced by Pharmacist #2, in which psychoactive medications were discussed, and whether RI #24's [MEDICATION NAME] had been addressed. EI # 9 stated they had discontinued another one of RI #24's medications, but had continued with the [MEDICATION NAME]. When asked what the [DIAGNOSES REDACTED].#24's [MEDICATION NAME], EI # 9 said Alzheimer's and [MEDICAL CONDITION]. When asked if those [DIAGNOSES REDACTED].# 9 said she did not know that those [DIAGNOSES REDACTED]. When questioned why RI #24 required the [MEDICATION NAME] after it had been discontinued for over a year, EI # 9 stated she would need to review the information in RI #24's chart to discuss the concern any further. On 3/3/20 at 4:39 p.m., EI # 9 returned and stated she had reviewed the information in RI #24's chart. When asked what information she had that justified the use of [MEDICATION NAME] for RI #24, EI # 9 said RI #24 had come back from the hospital with orders for it. EI # 9 went on to say that she did see notes that RI #24 had exhibited a few behaviors after returning from the hospital. When asked if the [MEDICATION NAME] was being used to address any specific target behaviors, EI # 9 said they had not attached any specific behaviors to the order for [MEDICATION NAME]. When asked where RI #24's behavior monitoring tools could be located, EI # 9 said they were captured in the nurses' notes. EI # 9 said in her review of RI #24's medical record, she found two instances of behaviors since RI #24's readmission on [DATE]: on [DATE] exit seeking was noted and there was another episode of the resident undressing. When asked if there had been any repetitive behaviors noted, EI # 9 said those were the only two instances she saw since [DATE]. When asked if that was enough to justify the use of the [MEDICATION NAME] for RI #24, EI # 9 said she could not just discontinue the medication. EI # 9 went on to say she did not know if anyone had specifically asked the Nurse Practitioner or Medical Director why RI #24 was back on the [MEDICATION NAME]. EI # 9 said the facility was responsible for ensuring they are in compliance with the requirements for antipsychotic usage. EI # 7, the Medical Director, was interviewed on 3/03/20 at 5:00 p.m. EI # 7 was asked if he recalled the MEDICATION ORDERS FOR [REDACTED]. EI # 7 said, yes, facility staff had called him and he was frustrated because RI #24 had been readmitted to the facility with an order for [REDACTED].# 7 said the order for the [MEDICATION NAME] never should have been entered/transcribed for RI #24 to continue. When asked what [DIAGNOSES REDACTED].# 7 said none in a dementia patient, only uncontrolled [MEDICAL CONDITION]. When asked how the facility had justified continuing the [MEDICATION NAME] for RI #24 after it had been discontinued for over a year, EI # 7 stated he does not use [MEDICATION NAME] for dementia, and the medication had been ordered for RI #24 in error.",2020-09-01
69,MERRY WOOD LODGE,15019,P O BOX 130,ELMORE,AL,36025,2020-03-03,812,F,1,1,LZCS11,"> Based on observations, interviews and a review of a facility policy titled, Food Storage: Cold Foods, the facility failed to ensure: 1. outdated food was not stored in the walk-in cooler, and 2. food items were labeled with a received date or use by date prior to storage in the walk-in cooler/reach-in freezer. These failures had the potential to affect 89 residents receiving meals from the kitchen out of 92 total residents residing in the facility. Findings Include: The facility policy titled, Food Storage: Cold Foods, with a revised date of 4/2018, included . Procedures . 5. All foods will be stored . labeled and date, and arranged . to prevent cross contamination . On 02/29/20 at 01:18 p.m., the surveyor observed food items in the walk-in cooler. There was one container of Sliced Peaches with no prepared date or use by date, one container of Strawberries prepared on 0[DATE] and labeled with a use by date of 01/30/20, one container of Prepared Yellow Salad Mustard with an opened date of 12/25/19 and labeled with a use by date of 01/25/20, and one bag of turkey with an open date of 02/15/20 and labeled with a use by date of 02/25/20. On 02/29/20 at 01:31 p.m., the surveyor observed food items in the reach-in freezer. The following items were observed: one bag of Spinach with an open date of 0[DATE] and no use by date, one bag of pepperoni slices with no open date and a use by date of 12/09/20, and one unopened roll of Ground Turkey with a received date of 12/13/19 and labeled with a use by date of 01/13/19. On 03/02/20 at 09:08 a.m., the surveyor conducted an interview with EI (Employee Identifier) #1, the Lunch Cook. The surveyor asked EI #1, what does a use by date mean. EI #1 stated, use it by that date or throw it away the next day. The surveyor asked EI #1 why the following items were observed in the walk-in cooler on 02/29/20 at 01:18 p.m.: one container of Sliced Peaches with no prepared date or use by date, one container of Strawberries prepared on 0[DATE] and labeled with a use by date of 01/30/20, one container of Prepared Yellow Salad Mustard with an opened date of 12/25/19 and labeled with a use by date of 01/25/20, and one bag of turkey with an opened date of 02/15/20 and labeled with a use by date of 02/25/20. EI #1 stated the items had been overlooked by staff. The surveyor asked EI #1 why the following items were observed in the reach-in freezer on 02/29/20: one bag of Spinach with an opened date of 0[DATE] and no use by date, one bag of pepperoni slices with no open date and a use by date of 12/09/20, and one unopened roll of Ground Turkey with a received date of 12/13/19 and a use by date of 01/13/19. EI #1 again stated these items had been overlooked by staff. EI #1 was asked, what was the facility's policy on labeling food items prior to storage. EI #1 stated all food items should be dated and labeled with open and use by date before placing in proper storage areas. The surveyor asked EI #1, what was the potential concern of storing foods not labeled with use by dates and storing items past their use by dates. EI #1 stated it could cause food borne illness or contamination, which could lead to sickness. On 03/02/20 at 09:36 a.m., the surveyor conducted an interview with EI #2, the Dietary Manager. The surveyor asked EI #2, who was responsible for ensuring the food items were discarded when out of date in the walk-in cooler/refrigerator/freezer. EI #2 stated, all staff. The surveyor asked EI #2, what was the potential concern of storing foods not labeled with use by dates and storing items past their use by dates. EI #2 stated, it could cause food borne illness, which could lead to sickness.",2020-09-01
70,MERRY WOOD LODGE,15019,P O BOX 130,ELMORE,AL,36025,2020-03-03,842,D,1,1,LZCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of a facility policy titled Medication: Administration: General, the facility failed to ensure nursing staff documented administration of Resident Identifier (RI) #24's [MEDICATION NAME] on 01/28/20 and 01/30/20 on the Medication Administration Record (MAR). This affected 1 of 20 sampled residents whose MARs were reviewed. Findings Include: A review of a facility policy titled Medication: Administration: General, revised [DATE], documented: .11. Document: 11.1 Administration of medication on Medication Administration Record (MAR). RI # 24 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #24's physician's orders [REDACTED]. A review of RI # 24's Narcotic Record for January 2020 documented one dose of [MEDICATION NAME] was taken out on 1/28/20 and another on 1/30/20. However, review of RI # 24's January 2020 MAR did not reflect [MEDICATION NAME] was administered on [DATE] or 1/30/20. On 3/1/20 at 5:00 p.m., an interview was conducted with Employee Identifier (EI) # 5, the Licensed Practical Nurse (LPN) that signed out the [MEDICATION NAME] on 1/28/20. EI # 5 was asked if she gave RI # 24 a [MEDICATION NAME] on 1/28/20. EI # 5 stated yes, it was documented on the narcotic book that she had signed one out. EI # 5 was asked if she marked the MAR when the [MEDICATION NAME] was given on 1/28/20. EI # 5 stated no, she forgot, but she should have signed it off on the MAR as adminsitered. EI # 5 was asked why she should mark it on the MAR. EI # 5 stated the next shift needed to know what was given. EI # 5 was asked how many doses of the [MEDICATION NAME] RI # 24 received. EI # 5 stated a total of two doses: one on 1/28/20 at 6:00 p.m. and one on 1/30/20 at 12:00 p.m. EI # 5 stated she did not give the the dose on 1/30/20. EI # 5 was asked if the nurse from 1/30/20 marked on the MAR that the [MEDICATION NAME] was given. EI # 5 stated no. An interview was completed with EI # 4, Registered Nurse/Unit Manager, on 3/3/20 at 9:40 a.m. When questioned about RI #24's Narcotic Record reflecting doses of [MEDICATION NAME] were signed out on 1/28/20 and 1/30/20 but administration was not documented on the MAR, EI # 4 stated it should have been documented in both places. EI #4 further explained the Narcotic Record reflected the medication was taken out, and the MAR should reflect the medication was administered. EI # 4 was asked if nurses should document on the MAR when they give medications. EI # 4 replied yes. EI # 4 was asked why nurses should document on the MAR. EI # 4 replied, to show the medication was given.",2020-09-01
71,MERRY WOOD LODGE,15019,P O BOX 130,ELMORE,AL,36025,2018-03-29,600,D,1,1,OSF111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, record reviews, and a review of the facility policy titled, Abuse Prohibition, the facility failed to ensure two residents were free from an incident of abuse. This affected RI (Resident Identifier) #s 94 and 2, two of twenty-five sampled residents. Findings Include: A review of the facility policy titled, Abuse Prohibition, with a revision date of 11/28/17, revealed: . POLICY . (name of HealthCare Company) will prohibit abuse, . Federal Definitions: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. Instances of abuse of all patients, irrespective of any mental or physical condition cause physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse includes hitting, slapping, pinching, kicking, . A review of two investigative summaries dated 1/19/18, revealed that on 1/13/18, RI #54 was observed to strike RI #2 and RI #94 with an open hand and sustained a skin tear to his/her hand. RI #54 struck RI #s 2 and 94 while urging the to Come on, let's go home. The Center Conclusion indicated under current definitions, (RI #54, the aggressor) acted in a deliberate manner in striking RI #2 and RI #94. The center's Abuse Coordinator concluded there was no evidence of physical harm as a result of the event. In the absence of physical harm, the Center concluded that physical abuse did not occur. A review of RI #54's Medical Record revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Quarterly MDS (Minimum Data Set) assessment, with an ARD (Assessment Reference Date) of 2/15/18, revealed RI #54 had a BIMS (Brief Interview for Mental Status) score of 4 out of a possible 15. This score indicated RI #54 was severely impaired in cognitive skills for daily decision making. A review of the Behavioral Symptoms section of the MDS revealed RI #54 exhibited no physical, verbal, or other behavioral symptoms towards others. A review of RI #2's medical record revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #2's Quarterly MDS, with an ARD of 3/20/18, revealed RI #2 had short term and long term memory problems and was severely impaired of cognitive skills for daily decision making. RI #2 was assessed on the MDS as demonstrating no physical, verbal, or other behavioral skills. A review of RI #94's medical record revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. RI #94 was admitted to the facility with [DIAGNOSES REDACTED]. A review of an Admission MDS, dated [DATE], revealed RI #94 had a BIMS score of 5 out of a possible 15. This score indicated RI #94 was severely impaired in cognitive skills for daily decision making. The resident displayed inattention and disorganized thinking. On 3/29/18 at 5:36 p.m., an unsuccessful attempt was made to interview the resident identified as the aggressor, (RI #54) related to the (MONTH) Facility Reported Incident. RI #54 was uncomfortable and did not remember. On 3/29/18 at 5:40 p.m., an interview was conducted with EI (Employee Identifier) #6, a CNA (Certified Nursing Assistant). EI #6 was asked if she had any knowledge of the alleged abuse. EI #6 responded, she could not even remember this. EI #6 exited the room to retrieve a copy of the interview and returned at 5:47 p.m. EI #6 stated, My mind is blank on this. EI #6 was asked if the interview she had in her hand was done by the Abuse Coordinator after the incident on 1/13/18. EI #6 stated she could not remember. On 3/29/18 at 5:54 p.m., an interview was conducted with EI #5, a LPN (Licensed Practical Nurse). EI #5 was asked if she had knowledge of the alleged abuse that occurred on 1/13/18. She replied, Yes, I was the charge nurse that evening. EI #5 was asked to describe RI #54 and the other residents that were seated at the table in the back of the room. EI #5 reported that RI #54 was sitting at a table on the inside with the wall to his/her right side, another resident to his/her left, and he/she could not get out. EI #5 said RI #54 had started to get restless in the evening and began telling the others it was time to get up and get a ride home. RI #54 was asked to sit down several times so he/she would not fall. EI #5 reported being at the desk. EI #5 was asked how far was she from the residents involved in the incident. EI #5 answered RI #54 was in the adjoining room. EI #5 added it was the full distance or farthermost away from the desk. EI #5 reported RI #54 told RI #94 to get up and come on, let us go. EI #5 said she was heading back there at that time and before she could get there, RI #54 had hit RI #94. When asked how this occurred, EI #5 answered RI #54 got up and reached across the table and slapped RI #94 with an open hand. RI #2 had his/her head down on the table and RI #54 told him/her to move, let him/her get out of there. Almost at that same time, RI #54 reached over and hit RI #2 on the back of the head, kind of like a slap on the back of the head. By this time, EI #5 reported she had made it to where the residents were. EI #5 managed to get to RI #2 before he/she hit RI #54 back. EI #5 reported she and EI #6, a (CNA), had gotten there about the same time. EI #5 reported EI #6 moved RI #54 out of the way and she moved RI #2 at about the same time. EI #5 reported RI #94 was away from the area by this time. EI #5 reported they checked to see if any of the three residents had any injuries and there were none except for a skin tear on RI #54's hand. EI #5 reported they started to notify the DON (Director of Nursing) and others to include the Psychiatrist. EI #5 reported the residents were separated at that time. EI #5 reported these were the actions she had taken in response to the incident. EI #5 was asked how did the alleged perpetrator and victim act towards one another prior to and after the incident and she answered they were just chatting. EI #5 was asked if the alleged perpetrator and/or victim exhibited any behaviors that would provoke one another. EI #5 answered they did not, RI #54 was just having a moment. EI #5 was asked if she reported the alleged abuse to any supervisors/administration and she answered yes. EI #5 was asked who she reported it to. EI #5 responded the DON, (she notified the administrator), the Psychiatrist, and she attempted to notify sponsors. EI #5 was asked what was their response. EI #5 answered the Psychiatrist got placement for evaluation of RI #54 because of aggression towards other residents. EI #5 added the Administrator had called back and interviewed her over the phone. On 3/29/18 at 7:09 p.m., an interview was conducted with EI #7, the Administrator/Abuse Coordinator. EI #7 was asked when he was notified of the alleged abuse involving RI #s 54, 94, and 2. EI #7 answered he was notified on the afternoon of Saturday, (MONTH) the 13 th, around 3 p.m EI #7 was asked what information was reported to him related to the alleged abuse. EI #7 responded it was reported to him that RI #2 was seated in a common area and RI #54 was attempting to leave that common area. RI #54 was moving past RI #2. RI #2 failed to move to allow passage, RI #54 struck RI #2 upon the head and face with an open hand. RI #94 was in the same area and was hit about the same time with an open hand. EI #7 was asked when and what actions were taken to protect the alleged victim from further abuse while the investigation was in process. EI #7 responded the aggressor was removed by staff to his/her room with a CNA, (EI #6), assigned to stay with her/him. Both victims (EI #2 and EI #94) were assessed for visible injury and queried (questioned). EI #7 was asked who he notified of the alleged abuse. EI #7 responded ADPH (Alabama Department of Public Health) via (by) the online reporting system. EI #7 was asked when he made the notification. EI #7 answered on 1/13/18 at 5:11 p.m EI #7 was asked if an outside entity was informed about the alleged abuse and he answered no. EI #7 was asked who was responsible for the investigation and he answered he was. EI #7 was asked if the investigation was completed or ongoing. EI #7 stated it was complete. EI #7 was asked what was the outcome. EI #7 answered his conclusion was that no abuse occurred. EI #7 stated, However, I came to that conclusion 1. because there was no obvious injury. 2. there was no confinement or punishment. EI #7 was asked when and what actions were taken to protect the alleged victim and residents at risk from further abuse while the investigation was in process. EI #7 reported RI #94 was removed from the secured unit, RI #2 was provided alternative seating in the common area, and RI #54 was transferred for evaluation and treatment outside the facility. EI #7 was asked what was the definition of physical abuse and he answered physical abuse includes hitting, slapping, pinching, kicking, etc (etcetera). EI #7 was asked if any of those occurred and he answered yes. EI #7 was asked why the allegation was not substantiated. EI #7 referred to his earlier conclusion of his investigation. EI #7 was asked what was the concern of not substantiating an allegation of abuse that investigations did substantiate. No answer was given. This deficiency was cited as a result of the investigation of complaint/report #AL 601.",2020-09-01
72,MERRY WOOD LODGE,15019,P O BOX 130,ELMORE,AL,36025,2018-03-29,812,F,0,1,OSF111,"Based on observations, an interview, review of the facility's policies and procedures titled, 4.0 Cleaning Standards and 4.7 Food Handling, along with a review of a facility document titled, Weekly Cleaning List, the facility failed to ensure: 1. the meal cart covers were sanitized prior to use and 2. chicken was thawed completely submerged in running water. This had the potential to affect all 92 residents who received meals from the kitchen. Findings Include: 1. A review of the facility's policy and procedure titled, 4.0 Cleaning Standards, with a revision date of 12/1/15, revealed: POLICY Written cleaning procedures are used to clean all equipment/areas in the Food and Nutrition Services Department. PURPOSE To ensure all food service equipment and areas are clean and sanitary. CART WASHING (HAND METHOD) WHEN: After Use . A review of a facility document titled, Weekly Cleaning List-(Name of facility), dated (YEAR)-2018, revealed: 1) Food Carts and Bun Rack Covers-Wiped Down after every shift break, lunch, and dinner . Monthly Cleaning List-(Name of facility), 1) Food Racks and Bun Covers-sprayed down with sanitizer and pressure washed, air-dried and brought back into facility . 2. A review of the facility's policy and procedure titled, 4.7 Food Handling, with a revision date of 11/28/17, revealed: POLICY Foods are stored, prepared and served in a safe and sanitary manner. PURPOSE To prevent bacterial contamination and the possible spread of infection. Food Safety During Meal Preparation and Service . 8. Frozen foods are thawed in the refrigerator and not at room temperature. Foods can be thawed if completely submerged under fast running cold water of at least 70 (circle representing degrees) F (Fahrenheit) or below. On 3/29/18 at 9:29 a.m., an observation was made of the kitchen. An observation was made of frozen pieces of chicken thawing in a sink under running water. Only the portion of the chicken the water was pouring directly onto was being wet. There was no submersion of the pieces of frozen chicken. A second observation was made of cart covers that were over meal trays placed on the racks. The cart covers were visibly soiled. This was observed on four carts. On 3/29/18 at 9:34 a.m., an interview was conducted with EI (Employee Identifier) #10, the Dietary Manager (DM). EI #10 was asked how should frozen chicken be thawed. EI #10 answered under refrigeration or under running water. EI #10 began to move the frozen chicken pieces to another sink and asked for a bowl to be brought to him. EI #10 stated, I didn't know she (the Cook) had it like this. EI #10 was asked who placed the thighs directly in the sink and he named the cook. When EI #10 was asked about the unclean appearance of the meal cart covers, he reported, Once in a while, I take them out and clean them. EI #10 was asked how did the carts look at that time. EI #10 answered, Need to be cleaned. EI #10 was asked how often should the cart covers be cleaned. EI #10 answered weekly and as needed. EI #10 added sometimes if he did not see residue, he did not clean them and last week he cleaned them twice. EI #10 was asked how he cleaned the cart covers. EI #10 stated he took them outside and sprayed off the cart covers and the actual carts too. EI #10 was asked how often should the actual carts be cleaned and he stated as needed. EI #10 was asked how should the carts be cleaned. EI #10 answered, I spray with sanitizing solution on the dock out back then pressure wash them and let them air dry. EI #10 was asked what was the facility's policy for cleaning of meal carts. EI #10 answered he did not know but he was always taught that it was as needed, no specific date. EI #10 was asked what was the facility's policy for cleaning meal cart covers and he stated the same as for the carts.",2020-09-01
73,MERRY WOOD LODGE,15019,P O BOX 130,ELMORE,AL,36025,2018-03-29,880,D,0,1,OSF111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and the review of facility policies, Waste Management, Medication Administration, Hand Hygiene, Glucose Meter, and Cleaning and Disinfecting, the facility failed to ensure: 1. medications were not placed on an unclean surface for RI (Resident Identifier) #22 and RI #55, 2. a glucose monitor was not placed on an unclean surface for RI #55 and then used for the resident, 3. hands were washed during medication administration, 4. gloves were used when handling the enteral infusion administration set, 5. a Gastrostomy tube infusion administration set was not covered with a unclean plastic cover and 6. a nurse did not dispose of a used glucose test strip in a trash can after use for RI #55 in his/her room. This affected RI #22, and RI #55, two of eleven residents observed during medication administration. Findings Include: A review of a facility policy and procedure, titled, Hand Hygiene with a revision date of 11/28/17, revealed: . POLICY Adherence to hand hygiene practices is maintained by all Center personnel. PR[NAME]ESS 1. Perform hand hygiene 1.1 Before patient care; . 1.4 After patient care; 1.5 After contact with patient's environment . A review of a facility policy and procedure titled, Cleaning and Disinfecting, with a revision date of 11/28/17, revealed: . PURPOSE To prevent infectious spread from items or environment to patients and/or staff. To ensure reusable medical equipment is cleaned and disinfected appropriately. PRACTICE STANDARDS . 5. Clean environmental surfaces, . using Environmental Protection (EPA) registered disinfectant . A review of a facility policy and procedure titled, Glucose Meter with a revision date of 5/15/17, revealed: .Glucose Meter 1. Gather equipment: . 2. Disinfect meter before and after each . use. A review of a facility policy and procedure titled, Waste Management, with a revision date of 10/31/16, revealed: . POLICY The Center's waste disposal system includes separate methods for handling regulated and non-regulated waste. These different types of waste are segregated . DEFINITIONS Regulated waste is also referred to as .medical waste . The Occupational Safety and Health Administration (OSHA) defines regulated waste as: Any liquid or semi-liquid blood or other potentially infectious material . PURPOSE To reduce risk of contamination from regulated waste and maintain appropriate handling and disposal of all waste . A review of RI #22's medical record revealed the resident was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of an Admission MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 01/07/18, revealed RI #22 was cognitively impaired with both long term and short term memory. The MDS also revealed RI # 22 was totally dependent on facility staff for all ADLs (Activities of Daily Living). At 11:49 a.m., on 3/28/18 EI (Employee Identifier) #1, a LPN (Licensed Practical Nurse} was observed preparing medications. EI #1 removed two packages of pills and one bottle of liquid medication and placed them on top of the medication cart. EI #1 removed a pill from each of the pill dispensing cards. A pill fell out of one cup onto the floor. EI #1, was observed picking up the pill off the floor with her bare hands. EI #1 was not observed washing her hands prior to continuing to set up the medications for administration. After the medications were prepared EI #1 gathered all medications and entered RI #22's room. All medications were placed on the top of a table at RI #22's bedside. EI #1, with gloves on, picked up a remote control off the fall mat on the floor to raise the bed up and without changing gloves or washing her hands, EI #1 left the resident's room. EI #1 was observed returning to RI #22's room. EI #1 did not change her gloves or wash her hands. EI #1 picked up the remote control for the bed from the floor and raised the bed up. Without washing her hands or changing gloves, EI #1 disconnected the enteral infusion administration set from RI #22's gastrostomy tube. EI #1 removed an uncovered, unprotected cap off of the top of the IV pole and placed the cap on the end of the enteral infusion administration set. On 03/29/2018 at 3:07 p.m. an interview was conducted with EI #1, a LPN. EI #1 was asked what did the facility policy say about hand washing during resident care. EI #1 replied wash hands for any provisions of care for a resident, before providing care, and after providing care, touching the resident before and after, and before and after procedures for the resident. EI #1 was asked to explain to this surveyor what happened at the medication cart while preparing RI #22's medications for administration. EI #1 stated one tablet fell on the floor. EI #1 replied she picked the pill up and disposed of it in the sharps container, then she obtained another pill for the resident. EI #1 was asked if she omitted anything after picking up a pill off of the floor. EI #1 replied she should have washed her hands before continuing with the mediation pass. EI #1 was asked why should she have washed her hands after picking up something off of the floor. EI #1 replied the floor is dirty, hands were contaminated after picking something up off of the floor. EI #1 was asked when the medications were taken into the resident's room where were they placed. EI #1 replied on a table next to the resident's bed. EI #1 was asked if there was anything different that she should have done. EI #1 replied not really, she could not think of anything. EI #1 was asked if the table was clean or if a barrier had been placed on the table before the medications were placed on the table. EI #1 replied no, she did not do that, but she should have. EI #1 was asked if there was a concern of placing medications on an unclean surface or not using a barrier. EI #1 replied she really did not know, she was always told to use a barrier with eye drops. EI #1 was aked what was done with the tip of the enteral infusion administration tube. EI #1 replied she took a cap off the top of the tube feeding pole and capped the the end of the enteral infusion tube with it. EI #1 was asked what should have been done after picking up the remote control for the bed off the floor twice. EI #1 replied she should have washed her hands. A review of RI #55's medical record revealed the resident was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a Re-Admission MDS with an ARD date of 02/15/18, revealed RI #55 was cognitively impaired with both long term and short term memory. RI #55 was totally dependent on facility staff for all ADLs. On 03/28/2018 at 12:04 p.m., EI#1 was observed preparing to perform a finger stick with a blood glucose monitor for RI #55. The blood glucose monitor was removed from the medication cart and placed upon the top of an unclean medication cart. An alcohol pad, lancet, and blood glucose monitor strip was also obtained and placed on top of the unclean medication cart. EI #1 gathered all of the above supplies and entered RI #55's room, placing all of the above supplies on an unclean table top. EI #1 placed clean gloves on without washing her hands. EI #1 performed a finger stick blood glucose test. All equipment and supplies were returned to the top of the table. EI #1 picked up the testing strip, held it in her left hand and removed her gloves. EI #1 disposed of the gloves with the test strip inside the gloves into RI #55's trash can. EI #1 picked up the blood glucose monitor and lancet without washing her hands or putting on gloves. EI #1 then returned to the medication cart. EI #1 placed the blood glucose monitor on top of the medication cart. EI #1 obtained a disinfectant disposable cleaning wipe and with bare hands EI #1 cleaned the blood glucose monitor with her bare hands and placed it on top of an unclean medication cart with no barrier present. EI #1 obtained insulin to be administered to RI #55 from the medication cart. EI #1 entered RI #55's room with a syringe of insulin and alcohol wipe which both were placed on top of an unclean table, without a barrier. EI #1, without washing her hands, placed gloves on and administered RI #55's insulin. EI #1 was observed leaving RI #55's room to obtain supplies and a cap to cover the end of the enteral infusion set. EI #1 returned to RI #55's room and without washing her hands and using her bare hands capped the end of the enteral infusion set then left the room without washing her hands. On 03/29/18 at 3:49 p.m., an interview was conducted with EI #1. EI #1 was asked what happened in the process of preparing to perform a blood sugar stick for RI #55. EI #1 replied she took the glucose meter out of the medication cart and laid it on top of the medication cart without cleaning it or using a barrier, which contaminated the machine. EI #1 also said she obtained a lancet, test strip and alcohol pad and placed them on top of the unclean medication cart without a barrier. EI #1 was asked where she placed the glucose meter, lancet and alcohol wipe. EI #1 said she placed all of the items on the table next to RI #55's bed, put on her gloves and did not wash her hands. EI #1 was asked what she did with the test strip after completing the finger stick. EI #1 said she pulled her gloves off and kept the strip rolled up inside of the gloves and threw it into RI #55's trash can. EI #1 was asked what was the facility policy about disposing of medical waste with blood present. EI #1 said she should have put it in the trash can on the medication cart.",2020-09-01
74,MERRY WOOD LODGE,15019,P O BOX 130,ELMORE,AL,36025,2018-12-13,656,D,0,1,D9RW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure Resident Identifier (RI) #46's electrical outlets were blocked as specified on his/her care plan. This affected one of 22 residents for whom care plans were reviewed. Findings include: RI # 46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #46's Annual MDS (Minimum Data Set) assessment, with an ARD (Assessment Reference Date) of 10/19/18, revealed RI # 46 had severely impaired cognitive skills and he/she required limited assistance from staff for all Activities of Daily Living. Review of RI #46 's comprehensive care plans revealed an intervention dated 1/26/18 for the following: . Provide (RI #46) with a barrier free environment; electric outlets blocked, walls free of removable items because (RI #46) runs (his/her) hands up and down walls as (he/she) walks about all areas . On 12/11/18 at 10:36 AM , RI #46 was observed in bed pulling the plug out of the outlet and and plugging it back in five times. On 12/11/18 at 3:54 PM, RI #46 was again observed plugging his/her radio in and unplugging it from the wall outlet above his/her bed four times. During an interview with Employee Identifier (EI) #3, the Recreational Director, on 12/13/18 at 3:15 PM, EI #3 said she had reviewed RI #46's care plan in 7/2018. She explained the previous Recreational Director had initiated the intervention to block the electrical outlets, but she left it in place when she reviewed the care plan. EI #3 and the surveyor then went to RI #46's room. After viewing the electrical outlets, EI #3 stated the electrical outlets/plugs were not blocked as specified on the care plan.",2020-09-01
75,MERRY WOOD LODGE,15019,P O BOX 130,ELMORE,AL,36025,2018-12-13,689,E,0,1,D9RW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of the Material Safety Data Sheet (MSDS) for a bottle of shampoo, the facilty failed to ensure: 1) Resident Identifier (RI) #46 was not observed repeatedly plugging and unplugging an electrical cord within reach of his/her bed; and 2) RI #21, a cognitively impaired resident, did not have access to a bottle of shampoo, that posed the risk for eye irritation and was identified as potentially harmful if swallowed. On 12/13/18, RI #21 was observed applying the shampoo to another resident's hair (RI #54) during an activity being held in the secure/dementia unit. These failures affected one of 22 sampled residents with electrical outlets in their rooms, and had the potential to affect all 33 residents residing on the secure unit. Findings include: 1) RI # 46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #46's Annual MDS (Minimum Data Set) assessment, with an ARD (Assessment Reference Date) of 10/19/18, revealed RI # 46 had severely impaired cognitive skills and he/she required limited assistance from staff for all Activities of Daily Living. Review of RI #46 's comprehensive care plans revealed an intervention dated 1/26/18 for the following: . Provide (RI #46) with a barrier free environment; electric outlets blocked, walls free of removable items because (RI #46) runs (his/her) hands up and down walls as (he/she) walks about all areas . On 12/11/18 at 10:36 AM , RI #46 was observed in bed pulling the plug out of the outlet and and plugging it back in five times. On 12/11/18 at 3:54 PM, RI #46 was again observed plugging his/her radio in and unplugging it from the wall outlet above his/her bed four times. On 12/13/18 at 10:39 AM, Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA), stated he had been working with RI # 46 for over ten years. EI #1 also stated RI #46 plugs and unplugs his/her radio all the time. On 12/13/18 at 10:54 AM, EI #2, another CNA, also stated RI #46 plays with the electrical plug by pulling it in and out of the outlet. During an interview with Employee Identifier (EI) #3, the Recreational Director, on 12/13/18 at 3:15 PM, EI #3 said she had reviewed RI #46's care plan in 7/2018. She explained the previous Recreational Director had initiated the intervention to block the electrical outlets, but she left it in place when she reviewed the care plan. EI #3 and the surveyor then went to RI #46's room. After viewing the electrical outlets, EI #3 stated the electrical outlets/plugs were not blocked as specified on the care plan. 2) RI #21 was admitted to the facility on [DATE]. RI #21's current [DIAGNOSES REDACTED]. Review of RI #21's annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 9/25/18, revealed RI #21 had both a short and long-term memory problem, moderately impaired daily decision making skills, and disorganized thinking continuously present during the assessment period. RI #21's care plan, initiated, 12/28/16, indicated RI #21 exhibited, or had the potential to exhibit behaviors, related to cognitive loss and poor impulse control. On 12/13/18 at 9:56 AM, RI #21 was observed standing beside another resident (RI #54) in the day area. RI #21 was pouring liquid shampoo on top of RI #54's head from an eight ounce bottle. On 12/13/18 at 10:37 AM the Surveyor accompanied Employee Identifier (EI) #5, Certified Nursing Assistant (CNA) into a resident bathroom (adjoining two resident rooms on the locked dementia unit). A 13.5 ounce bottle of dandruff shampoo and a pack of wipes were located on the back of the toilet. When the surveyor asked EI #5 what the items were, she stated someone left the shampoo and wipes. EI #5 explained items such as shampoo and wipes should be kept in a bag in the resident's top drawer. When asked what the potential harm in having shampoo accessible to residents could be, EI #5 said the residents could drink it, pour it out onto the floor, or put it in their hair or eyes. On 12/13/18 at 10:49 AM, the Surveyor and EI #5 entered another resident room (on the locked dementia unit). A bottle of shampoo and body wash was noted in the resident's top drawer. Also, a 10 ounce bottle of lotion, 34 ounce bottle of body wash, a 31 ounce bottle of shampoo, and another container of lotion were observed sitting on the counter beside the sink. EI #5 stated the items should not be out on the counter. When asked what the facility's policy was on storing these items, EI #5 said they should be kept in the resident's top drawer. Review of the Material Safety Data Sheet (MSDS) for the bottle of shampoo RI #21 was observed applying to RI #54's head revealed the following: . Section 2. Hazards Identification Classification ACUTE TOXICITY -ORAL- Category 5 (under certain circumstances, may pose a hazard to especially vulnerable populations) EYE DAMAGE/IRRITATION - Category 2B . Hazard Statements Causes Eye Irritation (MONTH) be harmful if swallowed . On 12/13/18 at 4:08 PM, EI #6, the Director of Nursing (DON), was interviewed. When asked where hygiene items, such as shampoo, should be stored on the locked unit, EI #5 said they are stored in the residents' rooms at their bedside; however, she stated the facility did not have a policy addressing this. When asked what the manufacturer's recommendations were for the shampoo RI #21 was observed applying to RI #54, EI #5 said avoid contact with eyes. EI #5 then said if the items are stored within residents' reach, they have access to them. During a follow-up interview with EI #5, DON, on 12/13/18 at 4:37 PM, EI #5 said the facility allows all residents to have personal items at their bedside; however, EI #5 indicated the bottle of shampoo RI #21 was observed applying to RI #54 was an item purchased by the facility. When asked if she had reviewed the MSDS sheet for that particular shampoo, EI #5 said she had not. The surveyor and EI #5 then reviewed the document together, and EI #5 agreed it indicated the shampoo could cause eye irritation and could be harmful if swallowed. When asked how the facility ensured that if residents were to access the shampoo that it would not pose a risk to them or other residents, EI #5 said that just because the residents have dementia they cannot take away their personal items (referring to shampoo). EI #5 did state, however, the facility was responsible for ensuring the safety of the residents. EI #5 was then asked of the residents on the dementia unit, how many were able to independently use the shampoo. EI #5 said none of them, because they all required staff supervision. When asked why the facility kept the residents' shampoo at their bedside if they were not able to use it independently, EI #5 said she did not know that it had to be kept there.",2020-09-01
76,HATLEY HEALTH CARE INC,15023,300 MEDICAL CENTER DRIVE,CLANTON,AL,35045,2017-03-16,314,D,0,1,4ZQH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, medical record reviews and a review of a facility document titled, Hand Hygiene Table, the facility failed to ensure Employee Identifier (EI) #1, a Registered Nurse (RN) washed her hands and changed gloves after cleaning the wound of Resident Identifier (RI) #3 and before continuing with RI #3's wound care. EI #1 further failed to ensure she washed her hands and changed gloves when she performed wound care on RI #10's multiple wounds. This deficient practice affected RI #3 and RI #10, two of three residents observed for wound care. Findings Include: A review of an undated facility document titled, Hand Hygiene Table, revealed hand hygiene should be performed using .Either Antimicrobial Soap and Water or Alcohol Based Hand Rub . After handling items potentially contaminated with blood, body fluids, secretions, or excretions . When during resident care, moving from a contaminated body site to a clean site . 1) RI #3 was admitted to the facility on [DATE]. RI #3's physician orders [REDACTED]. On 3/15/2017 at 11:46 a.m., EI #1, the RN/Wound Care Nurse, was observed performing wound care on the Stage 2 pressure ulcer on RI #3's sacrum. EI #1 washed her hands and applied gloves then removed the dirty dressing from RI #3's sacrum. EI #1 then ungloved and washed her hands and applied clean gloves. EI #1 then cleansed the wound with saline soaked gauze. EI #1 did not change gloves and wash hands after cleaning the wound. EI #1 then proceeded to cut the [MEDICATION NAME] gauze with sterile scissors and transferred it to the wound using sterile tweezers and secured it in place using gloved fingers; then covered the wound with the [MEDICATION NAME] Border dressing. On 3/16/2017 at 2:33 p.m. and interview was conducted with EI #1, the RN who performed the wound care on RI #3. EI #1 was asked when should gloves be changed and hands washed during wound care. EI #1 responded, prior to touching the old dressing, prior to cleaning the wound, and then prior to changing the dressing (before applying the new dressing). When EI #1 was asked if she washed her hands and changed her gloves after cleaning the wound of RI #3 and prior to applying the clean dressing, EI #1 replied, she thought she did, but was nervous. EI #1 further explained the potential harm in not washing the hands and changing gloves after cleaning the wound and before continuing with wound treatment could result in contamination of the wound, because you are going from a dirty to a clean area. On 3/16/2017 at 3:02 p.m. an interview was conducted with EI #2, the Infection Control Nurse. EI #2 was asked when during wound care should gloves be changed and hand hygiene performed. EI #2 explained, before starting wound care and anytime during wound care when going from dirty to clean. When asked if it was an acceptable practice to clean a dirty wound with hand held gauze and then, without changing gloves and washing hands, continue to apply the clean dressing, EI #2 responded, no. EI #2 further explained the harm in doing so could result in the spreading of bacteria. 2) RI #10 was admitted to the facility on [DATE]. RI #10's physician orders [REDACTED]. The RN/Wound Care Nurse, EI #1, was observed providing wound treatment to RI #10 on 3/15/2017 at 2:30 PM. EI #1 washed her hands and applied gloves before cleaning and measuring the area to RI #10's right buttock. Without removing her gloves and washing her hands, EI #1 then cleaned and measured the area to RI #10's left buttock. EI #1 was interviewed on 3/16/2017 at 2:42 PM. EI #1 was asked what should be done after cleaning one open wound before cleaning the second open wound. EI #1 stated to remove gloves and wash hands to avoid cross contamination. When asked why she had not removed her gloves and washed her hands between wound treatments, she stated she forgot.",2020-09-01
77,HATLEY HEALTH CARE INC,15023,300 MEDICAL CENTER DRIVE,CLANTON,AL,35045,2017-03-16,367,D,0,1,4ZQH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, medical record review and review of the facility's policy titled, Therapeutic Diets, the facility failed to ensure Resident Identifier (RI) #3 received a regular mechanical soft diet for breakfast and lunch on 3/15/2017. This affected RI #3, one of 14 sampled residents observed for meals. The facility's Resident Census and Conditions of Residents form, dated 3/14/2017, indicated 40 residents in the facility received mechanically altered diets. Findings Include: The facility's policy dated (MONTH) 2014 titled, Therapeutic Diets, documented Policy Statement It is the center policy to provide therapeutic diets in accordance with physician orders [REDACTED].>RI #3 was admitted to the facility on [DATE]. A review of RI #3's Annual Minimum Data Set with an Assessment Reference Date (ARD) of 9/13/2016, identified RI #3 as being cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. RI #3 was assessed as being independent with eating after set-up. RI #3's care plan titled Resident is at nutritional risk . with a problem onset date of 9/13/2016 last reviewed 3/7/2017 had an approach of . Diet as ordered . RI #3's (MONTH) (YEAR) Physician order [REDACTED].#3 was ordered a regular with mechanical soft diet. On 3/15/2017 at 8:20 a.m., during the breakfast meal observation, RI #3's plate contained two whole sausage patties. RI #3 consumed all of the oatmeal and half of the biscuit provided on the tray, but did not eat the sausage patties. On 3/15/2017 at 12:21 p.m., during the lunch meal observation, RI #3's plate contained two pieces of fried chicken, a whole thigh and leg. RI #3 consumed half of the chicken noodle soup, half of the roll provided, but did not eat the fried chicken. RI #3 explained to the surveyor that he/she had his/her top teeth pulled in (MONTH) (YEAR), and it hurt his/her gums to eat hard foods, so he/she did not eat the fried chicken. An interview was conducted with Employee Identifier (EI) #4, the Dietary Manager, on 3/16/2017 at 9:18 a.m. EI #4 was asked if whole sausage patties and a fried chicken leg and thigh were considered part of a mechanical soft diet. EI #4 replied, no ma'am. During an interview on 3/16/2017 at 9:45 a.m., EI #3, the Registered Nurse (RN) Manager of the hall where RI #3 resides, was asked what type of diet should RI #3 be receiving. EI #3 responded, regular diet with mechanical soft. When asked if whole sausage patties and a fried chicken leg and thigh were considered part of a mechanical soft diet, EI #3 responded, no. EI #3 further explained the potential harm in not following an order for [REDACTED].",2020-09-01
78,HATLEY HEALTH CARE INC,15023,300 MEDICAL CENTER DRIVE,CLANTON,AL,35045,2017-03-16,371,F,0,1,4ZQH11,"Based on observations, interview, and review of the facility's policies titled Receiving and Food and Supply Storage Procedures, the facility failed to ensure: 1) food items were properly labeled with the item name and use by date and were discarded once the use by date was exceeded; and 2) chicken was thawed in the walk-in cooler in a manner to prevent cross contamination. These failures had the potential to affect all residents receiving meals from the kitchen. The facility's Resident Census and Condition of Residents form, dated 03/14/2017, indicated 144 residents resided in the facility. Findings include: 1) Review of the facility policy titled Receiving, dated 05/2014, revealed the following: . Action Steps . 6. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. 7. All food items will be stored in a manner that insures appropriate and timely utilization based on the principles of first in - first out . During the initial tour of the kitchen on 03/14/2017 at 2:00 p.m., the following items were observed in the walk-in cooler: - two plastic containers of soup not labeled with an item name - chopped ham (identified by the Dietary Manager) not labeled with an item name - Bologna labeled with a use by date of 03/07/2017 - another container of Bologna with a use by date of 03/11/2017 - Vegetable soup labeled with a use by date of 03/12/2017 - Turkey labeled with a use by date of 03/11/2017 - Sausage for mechanical soft and puree diets with no use by date On 03/15/2017 at 11:28 a.m. three pans of jello were observed in the cooler with a use by date of 03/14/2017. Employee Identifier (EI) #4, the Dietary Manager, was interviewed on 03/16/2017 at 2:45 p.m EI #4 said food should be labeled upon placement into the cooler with the date received, open date, use by date, and what the item is. EI #4 said if items were not labeled with the use by date you would not know when it should be discarded. EI #4 also explained items past their use by dates should be discarded every morning. EI #4 said if items were stored past their use by dates they could grow bacteria and make people sick. 2) Review of the facility's policy titled Food and Supply Storage, undated, revealed the following: . REFRIGERATED STORAGE . Store fresh chicken in leak-proof containers. Thaw meat in the cooler. Raw meat must be stored below cooked products . During the initial tour of the kitchen on 03/14/2017 at 2:00 p.m., a metal pan containing thawing chicken was noted to contain bloody juices. The pan extended out past the shelf and was positioned right beside a box of tomatoes. Employee Identifier (EI) #4, the Dietary Manager, was interviewed on 03/16/2017 at 2:45 p.m EI #4 said when thawing chicken, cooked foods should be stored on top, then raw vegetables, and on bottom, the raw meats and poultry. After discussing the observation of the pan with bloody juices beside the tomatoes, EI #4 agreed the storage could cause disease.",2020-09-01
79,HATLEY HEALTH CARE INC,15023,300 MEDICAL CENTER DRIVE,CLANTON,AL,35045,2017-03-16,441,D,0,1,4ZQH11,"Based on observation, interview, and review of a document titled Hand Hygiene Table, the facility failed to ensure staff wore gloves when changing dirty bed linens. Further, staff did not wash hands or change gloves prior to handling the clean linens. This deficient practice was observed during one of one observation of staff changing dirty linens. Findings include: Review of the facility's undated document titled Hand Hygiene Table revealed staff should either use antimicrobial soap and water or an alcohol based hand rub before and after handling clean or soiled linens. On 03/15/2017 at 8:50 a.m., Employee Identifier (EI) #11, a Certified Nursing Assistant (CNA), was observed changing bed linens in Resident Identifier (RI) #14's room. EI #11 did not wear any gloves to remove the soiled linens from the bed and was observed holding the linens against her clothing. EI #11 then replaced the soiled linens with clean linens without washing her hands or applying gloves. EI #11, the CNA, was interviewed on 03/15/2017 at 2:45 p.m EI #11 said they strip resident beds on Mondays, Wednesdays, and Fridays. EI #11 agreed she did not wear gloves when changing the linens, but said she had never been told she had to. EI #11 was then asked when she should wash hands when changing bed linens. She stated she used hand sanitizer after she made the bed with clean linens, but said she had not cleaned her hands after she took the dirty linens off or put the clean ones on. EI #11 said she should wash her hands to avoid transferring anything to the clean linens. EI #2, the Infection Control Nurse, was interviewed on 03/16/2017 at 3:00 p.m EI #2 explained staff should wear gloves when changing bed linens to prevent the spread of infection. She also stated staff should wash hands before and after handling the linens. She said it was important for staff to wash hands after handling dirty linens, before touching the clean ones, to prevent transferring germs from the dirty to the clean.",2020-09-01
80,HATLEY HEALTH CARE INC,15023,300 MEDICAL CENTER DRIVE,CLANTON,AL,35045,2019-05-09,609,D,1,1,HQGM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, medical record reviews, review of facility policies titled, ABUSE, NEGLECT AND EXPLOITATION and REPORTING ALLEGATIONS OF ABUSE, NEGLECT AND EXPLOITATION and review of a document titled, Alabama Department of Public Health Online Incident Reporting System, the facility failed to timely report 13 allegations of abuse to the State Agency after the incidents occurred. This affected 14 of 71 facility reported incidents that were reviewed and affected Resident Identifier's (RI) #434, #74, #79, #47, #8, #69, #115, #22, #21, #104, #46, #38, #109, #70 and two unsampled, discharged residents. Findings Include: A review of the facility policy titled ABUSE, NEGLECT AND EXPLOITATION, with no date, revealed the following: .The facility must: .13. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: a. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, . A review of the facility's policy titled, REPORTING ALLEGATIONS OF ABUSE, NEGLECT AND EXPLOITATION, with no date, documented: Policy: It is the policy of this facility to report all allegations of abuse/neglect/exploitation to appropriate agencies in accordance with current state and federal regulations. Review of the Alabama Department of Public Health Online Incident Reporting System, revealed the following: 1) An incident of mistreatment was reported by a Certified Nursing Assistant (CNA), regarding another CNA being abnormally rough with Resident Identifier (RI) #434 on 04/25/2019 at 10:30 AM. This incident was not reported to the State Agency until 04/25/2019 at 3:29 PM. 2) An incident of verbal abuse was reported occurring on 01/12/2019 at 6:57 PM where RI #79 was fussing at other residents and staff and RI #74 threatened to kill RI #79. This incident was not reported to the State Agency until 01/14/2019 at 8:04 AM. 3) An incident of physical abuse was reported occurring on 01/08/2019 at 10:00 AM where RI #47 reported that a CNA, was rough and jerked RI #47 in the bathroom. This incident was not reported to the State Agency until 01/09/19 at 1:37 PM. 4) An incident of physical abuse was reported occurring when RI #8 reported that a CNA, was rough when giving a shower on 11/22/2018 at 5:00 p.m. This incident was not reported to the State Agency until 11/23/2018 at 10:02 AM. 5) An incident of physical abuse was reported occurring on 10/31/18 at 5:54 PM where RI #115 hit RI #69 on the shoulder and RI #69 pushed RI #115 onto the bed. This incident was not reported to the State Agency until 11/01/18 at 7:22 AM. 6) An incident of neglect was reported occurring on 10/31/18 at 6:00 PM where a CNA, refused to change RI #22 and talked hateful to RI #22. This incident was not reported to the State Agency until 11/01/18 at 9:02 AM. 7) An incident of physical abuse was reported occurring on 10/30/18 at 8:30 PM where RI #104 stated that RI #21 grabbed and bent his/her hand back. This incident was not reported to the State Agency until 10/31/18 at 7:36 AM. 8) An incident of physical abuse was reported occurring on 10/30/18 at 8:30 PM where RI #115 went up to RI #79 and started slapping RI #79's hands. This incident was not reported to the State Agency until 10/31/18 at 7:47 AM. 9) An incident of physical abuse was reported occurring on 10/27/18 at 5:00 PM where RI #115 walked into RI #46's room and hit RI #46 on the left shoulder. This incident was not reported to the State Agency until 10/29/18 at 7:08 AM. 10) An incident of physical abuse was reported occurring on 10/23/18 at 12:00 AM where RI #38 went into RI #46's room and RI #46 twisted RI #38's arm. This incident was not reported to the State Agency until 10/25/18 at 4:27 PM. 11) An incident of physical abuse was reported occurring on 09/16/18 at 8:45 AM where RI #79 came around the corner of the nurse's station where RI #109 was sitting in a wheelchair and RI #109 kicked RI #79's wheelchair and RI #79 grabbed RI #109's lower leg and squeezed it. This incident was not reported to the State Agency until 09/16/18 at 2:31 PM. 12) an incident of physical abuse on 09/10/18 at 1:15 PM where a unsampled, discharged resident came in to the activity room and tapped RI #70 on the arm and told RI #70 to move because it was his/her spot. This incident was not reported until 09/12/18 at 1:43 PM, 13) An incident of injuries of unknown source was identified on 08/28/18 at 9:30 PM when RI #88 was noted to be guarding his/her right arm per EI #12, Licensed Practical Nurse (LPN), and xrays revealed a [MEDICAL CONDITION] distal humerus and elbow joint. The incident was not reported to the State Agency until 08/29/18 at 12:26 PM. 14) An incident of physical abuse was reported occurring on 07/14/18 at 10:00 PM where another unsampled, discharged resident complained that RI #69 (spouse) was hitting him/her in the chest. This incident was not reported to the State Agency until 07/15/18 at 6:16 AM. On 05/09/19 at 2:45 p.m., an interview was conducted with EI #2, Registered Nurse (RN)/Assistant Director of Nursing (ADON)Abuse Coordinator. EI #2 was asked, when should an allegation of abuse be reported to the State Agency. EI #2 said within two hours. EI #2 was then asked to individually review the 14 incidents listed and asked whether they were reported to the State Agency within the designated two hour time frame. EI #2 answered no, to all 14 incidents and explained that some of the incidents had been slid underneath her office door and she found them on her return to work. She further stated that she had found one of the incidents written on a 24 hour report form. On 05/09/19 at 4:08 p.m., an interview was conducted with EI #1, Administrator. EI #1 was asked if he had been made aware of the facility not reporting incidents timely to the State Agency. EI #1 said yes. EI #1 was asked what was the reason identified for the reports being submitted late. EI #1 stated they had been doing education with the employees identified for not reporting timely and that all employees receive abuse training twice a year. This citation resulted from the investigation of complaint/report # AL 246.",2020-09-01
81,HATLEY HEALTH CARE INC,15023,300 MEDICAL CENTER DRIVE,CLANTON,AL,35045,2019-05-09,761,D,0,1,HQGM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of a facility policies titled, STORAGE OF MEDICATIONS AND BIOLOGICALS and CONTROLLED MEDICATION STORAGE, observations and interviews, the facility failed to ensure: 1. the A Wing medication storage room / cabinet did not contain expired medications, including five unopened bags of normal saline intravenous fluids, along with eight other medication including creams, ointments, gel, liquid and tablets and 2. the Medication Cart for the 600 hall did not include a medication (narcotic) labeled with an unreadable expiration (discard) date. This affected one of two medication rooms observed and one of four medication carts observed. Findings include 1. A review of the facility's policy titled, 3.1: STORAGE OF MEDICATIONS AND BIOLOGICALS, with a date of 3/11, revealed: . Procedure . 11. Outdated, contaminated, or deteriorated medications and . are removed from stock, disposed of according to procedures for medication disposal, . The Surveyor reviewed another facility policy titled, 4.3: Disposal of Medication Non-Controlled Medication Destruction, with a date of 3/11, . Policy . expired medications, .are destroyed or disposed of per federal/state regulations. On 05/08/19 at 04:29 pm, the Surveyor observed, with Employee Identifier (EI) # 5, the A Wing Medication Storage Room. Observations were made of the following items: One of the lower cabinets contained a paper bag with expired intravenous fluids (see the expiration dates below). The Surveyor observed with EI# 5, a total of five unopened bags of normal saline 0.9 Sodium Chloride injection, labeled for a resident,t one bag with an expiration of [DATE] (YEAR), one bag with an expiration date of (MONTH) (YEAR) and three bags with an expiration date of (MONTH) (YEAR). The Surveyor also observed, with EI# 5, an upper cabinet containing the following: 1. one opened bottle of Icy Hot Arthritis pain relief lotion 5.5 ounces with a handwritten first name on it, expired 6/14; 2. one opened tube of Preparation H ointment 2 ounces with Resident Identifier # 32 hand written name on it, expired 6/2017; 3. one opened tube of Capzasin HP Arthritis Pain relief topical [MEDICATION NAME] cream 1.5 ounces, expired 7/17; 4. one opened tube of Risamine Ointment with a label for a resident, expired 3/18; 5. one opened [MEDICATION NAME] 1 percent Iodoquinol 1 percent cream with label for a resident, expired 7/17; 6. one opened bottle of Allergy Tablets [MEDICATION NAME] 4 mg tablets 1000 tablets with a resident's name hand written on it expires 3/18; 7. one opened bottle of Pepto Bismol Max [MEDICATION NAME] 4 ounce bottle, expired 2/16 and 8. one tube of [MEDICATION NAME] maximum tooth ache get unopened instant pain relief .42 ounces, expired (YEAR), with a resident's name handwritten on the box. On 05/08/19 at 05:37 pm, the Surveyor interviewed EI #5. EI #5 was asked if she observed expired intravenous fluids with the surveyor in the Medication Storage Room cabinet. EI # 5 replied, yes ma'am. She was asked, how many bags of expired fluids were in the cabinet. EI# 5 replied, to be honest it was four or five. EI #5 was asked, did she observe eight medications including, tubes of ointments,creams, lotion, liquid medication and tablets that had expired, with the surveyor in the medication storage room cabinet. EI#5 replied, yes ma'am. She was asked, what was the facility policy regarding expired medication in the medication storage room/cabinet. EI# 5 replied, expired medications are supposed to be turned in to the Director Of Nursing (DON) to be destroyed. EI #5 was asked, according to the policy what was the correct time frame expired medication should be turned in to the DON. EI# 5 replied, she could not tell the exact time frame, but in a timely manner. EI #5 was asked, what was the potential harm for having expired medications including, intravenous fluids, creams, liquids and tablets in the medication storage room cabinets. EI# 5 replied, the potential harm was it could be used on another resident. 2. A review for the facility policy titled, 3.2 CONTROLLED MEDICATION STORAGE revealed: . 10. Controlled medication expiration dates and storage dates are periodically monitored by the consultant staff. On 05/08/19 at 08:38 am, the Surveyor observed with EI# 6, the Medication Cart for the 600 hall and found: 1. Label -Resident # 92 [MEDICATION NAME] 0.5 mg total 27 verified, 3/8/19 date on top right corner of the label. Part of the label was cut off bottom of card, was unreadable. The Surveyor and EI #6 were unable to read the Discard after date. The Surveyor asked EI #6 how did she know what the expiration date was for that medication. EI# 6 replied, you don't positively know. On 05/09/19 at 08:10 am, the Surveyor interviewed EI# 6. EI #6 was asked, on (MONTH) 8th 2019 did she observe an [MEDICATION NAME] card of medication that had an unreadable discard date, on the medication cart in the locked narcotic box. EI# 6 replied, yes she did and she did correct that. EI #6 was asked was medication signed out off on the card that had an unreadable expiration date. EI# 6 replied, yes there were three or four of them. EI #6 was asked what was the potential harm with a medication on the cart with an unreadable expiration date. EI# 6 replied, it could have been expired, the medication strength may not have been as potent. And EI# 6 continued, they should not be giving out dated medications.",2020-09-01
82,HATLEY HEALTH CARE INC,15023,300 MEDICAL CENTER DRIVE,CLANTON,AL,35045,2019-05-09,880,D,0,1,HQGM11,"Based on observation, interviews and a review of a facility policy titled, Infection Prevention and Control Program, the facility failed to ensure EI (Employee Identifier) #4 folding laundry, did not allow the laundry to touch the floor or her clothing. This affected 1 of 1 laundry staff observed folding clean laundry. Findings include: A facility policy titled, Infection Prevention and Control Program, date implemented, 11/28/17, revealed, Policy: It is a policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy Explanation and Compliance Guidelines: .10. Linens: a. Laundry and direct care staff shall handle, store, process and transport linens so as to prevent spread of infection. d. Never place linen on floor . An observation was made on 05/09/19 at 10:11 a.m. of the laundry area. EI #4 was observed folding sheets, gowns, and under pads. Two sheets were observed touching the floor while being folded. Multiple sheets, gowns and under pads were observed touching EI #4 's clothing as he/she folded. On 05/09/19 at 10:38 AM, an interview was conducted with EI #4 , laundry staff. EI #4 was asked, should laundry touch your clothing while folding. EI #4 replied, she did not think so. EI #4 was asked, should the laundry touch the floor while folding. EI #4 replied, no. EI #4 was asked, did the laundry touch her clothing, or the floor, when she was folding clothes. EI #4 replied, if so, it was by accident, the fans were blowing everywhere. EI #4 was asked, where was that load of laundry going, that she was folding. EI #4 replied, each wing, it was divided up. EI #4 was asked, what was the potential concern of the laundry touching she clothing or touching the floor. EI #4 replied, it would be considered dirty. On 05/09/19 at 10:48 AM, an interview was conducted with EI #3 Assistant Director Of Nursing (ADON)/ Infection Control. EI #3 was asked, should laundry touch the floor while being folded. EI #3 replied, no. EI #3 was asked, should laundry touch an employee's clothing while being folded. EI #3 replied, no. EI #3 was asked, what was the potential concern of the laundry touching the floor or the employee's clothing. EI #3 replied, infection control.",2020-09-01
83,HATLEY HEALTH CARE INC,15023,300 MEDICAL CENTER DRIVE,CLANTON,AL,35045,2018-05-10,584,D,0,1,YKK111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and review of a facility policy titled, Resident Rights Policy, the facility failed to ensure RL (Room Locator) 1-4 were free of scrapes, gashes, cracks, and missing paint on the walls. The facility further failed to ensure Resident Identifier (RI) #'s 15, 31 and 93's rooms did not have deep scrapes, dents, and missing paint on the walls, and RI #31's arm rests on his/her wheel chair were not torn. This affected three of 111 rooms in the facility, and affected one of 10 wheelchairs observed during the survey. Findings Include: (1) A review of a facility policy titled, Resident Rights Policy, with a revised date of 12/19/16, revealed the following: . Safe environment. The resident has a right to a . comfortable and Homelike environment . On 05/08/18 at 4:57 p.m., the surveyor observed in RL #1, on the A and B side of the room, walls with deep punctures in the sheetrock, and a brown stain in the ceiling on the B side of the room. On 05/08/18 at 5:12 p.m., the surveyor observed in RL #2, on the A and B side of the room, walls with gashes and holes in sheetrock. On 05/08/18 at 5:30 p.m., the surveyor observed in RL #3, the ceiling had cracked plaster and brown stain on the left side. On 05/09/18 at 8:36 a.m., the surveyor observed in RL #4, chipped paint on the walls on both the A and B sides of the room. Behind the head board on the A side of the room there was a hole in the wall. In the bath room, in the middle of the wall, was chipped paint and there was a hole in the wall in the corner behind the dresser on the B side of the room. On 05/10/18 at 5:45 p.m., the surveyor toured rooms in the facility with Employee Identifier (EI) #19, the Maintenance Director and observed the same issues previously documented. On 05/10/18 at 6:10 p.m., the surveyor conducted an interview with EI #19. EI #19 was asked when touring with the surveyor, did he observe in RL #'s 1-4 scrapes, holes, gashes, cracks and missing paint on the walls. EI #19 replied, yes ma'am. EI #19 was asked why were there holes, gashes, cracks, scrapes and missing paint on the walls. EI #19 replied, from the beds hitting the walls and bedside tables hitting the wall. EI #19 was asked when was a walk through conduced last. EI #19 replied, he walked through every day. EI #19 stated he had also done a walk through of residents' rooms in (MONTH) of (YEAR). EI #19 further stated maintenance goes in the rooms quarterly. EI #19 was asked when looking at the holes, scrapes, gashes and missing paint on the walls, was that a homelike experience for the residents. EI #19 replied no ma'am. EI #19 was asked who was responsible for repairing holes, scrapes, gashes and missing paint on the residents walls. EI #19 replied, the Maintenance Director. EI #19 was asked how did he think it made the residents feel with holes, scrapes, gashes, and missing paint on the walls. EI #19 replied, not very happy. (2) RI #15 was admitted to the facility on [DATE], and readmitted on [DATE]. On 05/09/18 at 8:53 a.m., the surveyor observed a wall in RI #15's room with pieces of missing paint on the lower wall. EI #15 said it had been that way for a while. On 05/10/18 at 8:02 a.m., the surveyor observed the wall to remain the same. RI #93 was admitted to the facility on [DATE]. On 05/08/18 at 5:30 p.m., the surveyor observed missing pieces of paint and sheetrock on the wall on the left side of RI #93's bed. On 05/09/18 at 8:14 a.m., the wall in RI #93's room remained the same. On 05/10/18 at 7:54 a.m., the surveyor observed the wall to remain in the same condition. RI #31 was admitted to the facility on [DATE]. A Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 02/05/18, revealed RI #31 used a wheelchair. On 05/09/18 at 9:47 a.m., the surveyor observed missing paint on the wall near the left side of RI #31's bed. On 05/09/18 at 11:40 a.m., the surveyor observed the left and right arm rest on RI #31's wheelchair to be torn. On 05/10/18 at 8:06 a.m., the wall in RI #31's room remained in the same condition. On 05/10/18 at 8:16 a.m., the surveyor observed the arm rests on RI #31's wheelchair remained the same. On 05/10/18 at 5:45 p.m., the surveyor conducted an interview with EI #19. EI #19 was asked who was responsible for repairing the residents wheelchair. EI #19 replied, EI #20, the Maintenance worker. EI #19 was asked why was RI #31's wheel chair arm rest not repaired. EI #19 replied he wrote it up to be repaired that morning, referring to a work order. EI #19 was asked had it been repaired yet. EI #19 replied, no ma'am. EI #19 was asked what kind of harm could a cracked wheel chair arm rest cause the resident. EI #19 replied, skin tear and bacteria. EI #19 was asked why was it important to keep residents wheel chair arm rests repaired. EI #19 replied, so the resident would not get injured or an infection. EI #19 was asked to describe RI #31's wheelchair armrest. EI #19 replied, it looked like the top layer had come off, it looked used, and the vinyl had separated from the mesh. EI #19 was asked how did he think the resident felt having damaged arm rest on his/her wheelchair. EI #19 replied, he/she may have felt it was dangerous or it was not perfect.",2020-09-01
84,HATLEY HEALTH CARE INC,15023,300 MEDICAL CENTER DRIVE,CLANTON,AL,35045,2018-05-10,641,D,0,1,YKK111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Resident Identifier (RI) #89's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 03/27/18, was coded correctly under urinary continence for RI #89's use of a Foley catheter. Findings Include: RI #89 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a Quarterly MDS dated [DATE], revealed RI #89 was coded as always continent. On 05/08/18 at 5:00 p.m., RI #89 was observed in bed. A Foley catheter was observed hanging to the left side of the bed contained in a privacy bag. On 05/10/18 at 1:50 p.m., an interview was conducted with Employee Identifier (EI) #4, a Registered Nurse (RN)/MDS Coordinator. EI #4 was asked if RI #89 had a Foley catheter. EI #4 replied, yes. EI #4 was asked, when was RI #89's Foley catheter ordered. EI #4 replied she was not sure, RI #89 had it a long time. EI #4 was asked how should the urinary continence section on the 03/27/18, MDS be coded. EI #4 replied, Foley catheter and not rated which was a 9. EI #4 was asked in the under urinary continence section, it was coded as 0 always continent, would that assessment be accurate. EI #4 replied, no. EI #4 was asked what was the risk of the MDS not being coded accurately. EI #4 replied, some one may not realize the resident had a Foley catheter.",2020-09-01
85,HATLEY HEALTH CARE INC,15023,300 MEDICAL CENTER DRIVE,CLANTON,AL,35045,2018-05-10,686,D,0,1,YKK111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to ensure: (1) Resident Identifier (RI) #53, a resident at risk for developing pressure ulcers, intervention to have his/her feet elevated off the mattress, and to wear heel protectors while in bed was implemented. This was observed on two of three days of the survey; and (2) RI #15 and RI #93, residents at risk of developing pressure ulcers, had cushion on the oxygen tubing behind their ears. This was observed on two of three days of the survey. These deficient practices affected RI #53, one of three residents sampled for pressure ulcers, and RI #15 and RI #93, two of three sampled residents using oxygen: Findings Include: (1) RI #53 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #53's Pressure Ulcer care plan, with a Problem Onset date of 06/14/17, documented: . Approaches . * Apply heel protects to feet while in bed and float heels . A Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 02/21/18, identified RI #53 as being at risk for pressures ulcers. On 05/09/18 at 10:32 a.m., the surveyor observed the Treatment Nurse, Employee Identifier (EI) #11, prepare to provide wound care to the top of a toe on RI #53's right foot. RI #53's feet were on the mattress and no heel protectors were worn at this time. On 05/10/18 at 8:01 a.m., the surveyor observed RI #53's bare feet on the mattress, with no heel protectors on. On 05/10/18 at 2:30 p.m., the surveyor conducted an interview with EI #12, RI #53's assigned Certified Nursing Assistant (CNA). The surveyor asked EI #12 how should RI #53's feet be when he/she was in bed. EI #12 said they should be elevated on pillows so RI #53's heels would not rub on the bed and get a pressure sore on them. The surveyor asked EI #12, according to RI #53's plan of care, what should be on RI #53's feet. EI #12 said heel protectors. When asked what was the rationale for RI #53 having on heel protectors, EI #12 replied, so RI #53's feet would be off the bed and it would release pressure from his/her heels. EI #12 and the surveyor went to RI #53's room to see if there were heel protectors in the room. EI #12 looked in RI #53's dresser drawers and stated there were no heel proctors in RI #53's room. (2) RI #15 was admitted to the facility on [DATE], and readmitted on [DATE], with a [DIAGNOSES REDACTED]. A Significant Change MDS assessment, with an ARD of 01/19/18, identified RI #15 as being at risk for pressures ulcers. RI #15's Oxygen Therapy care plan, with a Problem Onset date of 02/09/18, documented: . Approaches * Check cushion behind my ears q (every) shift and PRN (as needed) to assure in place appropriately . RI #15's (MONTH) (YEAR) Physician order [REDACTED].> . OXYGEN @ (at) 3LPM (liters per minute) VIA (by way of) NC (nasal cannula) DAILY PRN SHORTNESS OF BREATH . On 05/09/18 at 8:35 a.m., the surveyor observed RI #15's oxygen infusing at 3 liters per minute. There was no cushion on the tubing behind RI #15's ears. On 05/10/18 at 8:48 a.m, the surveyor again observed RI #15 wearing oxygen. There remained no cushion on the tubing behind RI #15's ears. On 05/10/18 at 2:53 p.m., the surveyor conducted an interview with EI #13, the nurse assigned to care for RI #15. The surveyor asked EI #13, according to the care plans of residents who are receiving oxygen, what should they have on the tubing behind their ears. EI #13 said cushion. The surveyor asked EI #13 if there was no cushion on the tubing behind the ears, were the care plans being followed. EI #13 said no. The surveyor asked EI #13 to look behind RI #15's ears and asked did RI #15 have cushion on the tubing behind his/her ears. EI #13 said no. RI #93 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #93's Oxygen Therapy care plan, with a Problem Onset date of 04/13/17, documented: . Approaches * Check cushion behind ears q shift and prn to assure in place appropriately . An Annual MDS assessment, with an ARD of 03/13/18, identified RI #93 as being at risk for pressures ulcers. RI #93's (MONTH) (YEAR) Physician order [REDACTED].> . OXYGEN AT 2 LITERS VIA NASAL CANNULA . On 05/08/18 at 5:29 p.m., the surveyor observed RI #93's oxygen infusing at 2 liters per minute. There was no cushion on the tubing behind RI #93's ears. On 05/10/18 at 7:56 a.m, the surveyor again observed RI #93 wearing oxygen. There remained no cushion on the tubing behind RI #93's ears. On 05/10/18 at 2:53 p.m., the surveyor conducted an interview with EI #13. The surveyor asked EI #13 to look behind RI #93's ears and asked did RI #93 have cushion on the tubing behind his/her ears. EI #13 said no. The surveyor asked EI #13 what was the rational for ensuring cushion was on the tubing behind the residents ears. EI #13 replied, to prevent breakdown.",2020-09-01
86,HATLEY HEALTH CARE INC,15023,300 MEDICAL CENTER DRIVE,CLANTON,AL,35045,2018-05-10,812,F,0,1,YKK111,"Based on observations, interviews and review of facility policies titled, Equipment, Food Storage: Dry Goods, Service Line Checklist, Food: Preparation, and Staff Attire and review of the (YEAR) Food Code U.S. (United States) Public Health Service FDA (Food and Drug Administration), the facility failed to ensure: 1) a stored blender was free of debris; 2) food items in the dry storage area was sealed; 3) temperatures of all food items on the trayline were taken; and 4) dietary workers hair was completely enclosed in their hairnets and strains of loose hair was not on the back of a dietary worker's shirt. This had the potential to affect 131 of 132 residents who received meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Equipment, with a revised date of 09/17, revealed: Policy Statement All food service equipment will be clean, sanitary . Procedures . 3. All food contact equipment will be cleaned and sanitized after every use. A review of the (YEAR) Food Code, revealed: . 4-701.10 Food Contact Surfaces . Equipment Food-Contact Surfaces . shall be SANITIZED. 4-702.11 Before use After Cleaning. FOOD-CONTACT SURFACES of EQUIPMENT shall be SANITIZED Before Use after cleaning. On 05/08/18 at 4:57 p.m., the surveyor observed powdered sugar and icing located on the bowl holder and on the back plate of the mixer. The mixer was stored away under a plastic covering to be used again. There was chocolate icing on the bag that covered the mixer. On 5/10/18 at 1:13 p.m., an interview was conducted with (Employee Identifier) EI #23, a Dietary Aide. EI #23 was asked what did she see on the mixer on 05/08/18. EI #23 replied, powdered sugar. EI #23 was asked was it put away for next use. EI #23 replied, yes ma'am. EI #23 was asked, who was responsible for making sure equipment was clean before covering it up. EI #23 replied, the last person who used it. EI #23 was asked why was it important that equipment was clean when putting it away. EI #23 replied, everything was suppose to be sanitized. EI #23 was asked, what was the facility's policy on cleaning equipment. EI #23 replied, clean the work area when finished. 2) A review of a facility policy titled, Food Storage: Dry Goods, with a revised date of 09/17 revealed: . Procedures . 5. All packaged . food items will be kept clean, dry and properly sealed. 6. Storage area will be . arranged for easy identification, and date marked as appropriate. On 05/08/18 at 4:24 p.m., the surveyor toured the storage area along with EI #23. Pure cane sugar was in a large zip lock bag and the zip lock bag was not sealed. The open date was 04/19/18, but no use by date was observed. There was a large zip lock bag with cake mix in it. The open date was 05/03/18 but no use by date was observed and the the zip lock bag was not sealed. There was a large bag of Rottini noodles opened on 03/21/18. The noodles were tied, but there was a large hole at the opening of the bag exposing the noodles and there was no use by date. On 05/10/18 at 1:18 p.m., an interview was conducted with EI #23. EI #23 was asked while touring the dry storage area what did she notice about the cake mix, bag of sugar and Rottini noodles. EI #23 replied, they were all opened. EI #23 was asked how should opened food be properly stored. EI #23 replied, in a sealed bag. EI #23 was asked what was the problem with leaving opened food items exposed or unsealed. EI #23 replied, it could cause bugs and was unsanitary. EI #23 was asked who was responsible for making sure food was stored properly. EI #23 replied, the person that used it last. 3) A review of a facility document titled, Service Line Checklist, with a date of 05/09/18, revealed during the lunch meal, no temperature of the main meat, (chicken) was taken and recorded. A review of a document titled, Food: Preparation, with a revised date of 9/17, revealed: . Procedures . 13. All foods will be held at appropriate temperatures, greater than 135 F (Fahrenheit) .14. Temperature for TCS (Time Temperature Control for Safety) foods will be recorded at time of service . On 05/09/18 at 10:25 a.m., during the lunch meal trayline, the surveyor observed EI #18, the Dietary Aide, taking temperatures on the trayline. All temperatures of the food were taken and written down except the temperature of the fried chicken. On 05/10/18 at 1:27 p.m., the surveyor conducted an interview with EI #18. EI #18 was asked, who was responsible for taking temperatures on the tray line. EI #18 replied, the head cook. EI #18 was asked what did the facility policy say about taking food temperatures on the tray line. EI #18 replied, take the temperature of food once it was put on the tray line. EI #18 was asked why should food temperatures be taken on the tray line. EI #18 replied, to make sure it was above the temperature danger zone. EI #18 was asked when should food temperature be taken on the tray line. EI #18 replied, once the food was set up, and right before you start serving. EI #18 was asked what was the potential harm when food items were not taken on the tray line. EI #18 replied, she had to make sure it was above the danger zone because if it was below it could grow bacteria. EI #18 was asked did she take the temperature of the chicken on 05/09/18. EI #18 replied, no ma'am. EI #18 said she over looked that one. EI #18 was asked where was it documented that she took the temperature of the chicken on the tray line. EI #18 said that it was not on there (menu log) On 05/10/18 at 1:40 p.m., an interview was conducted with EI #17, the Kitchen Manager. EI #17 was asked who was responsible for taking the temperatures on the trayline. EI #17 replied, the head cook. EI #17 was asked what did the facility's policy say about taking temperatures of food items on the tray line. EI #17 replied, TCS foods would be recorded at time of service. EI #17 was asked where was it documented. EI #17 replied, it was not. EI #17 said the square was empty, referring to the lunch menu log. 4) A review of a facility policy titled, Staff Attire, with a revised date of 9/17, revealed: . Procedures 1. All staff members will have their hair off the shoulder, confined in a hair net or cap . On 05/09/18 at 11:07 a.m., the surveyor observed three Dietary Aides, EI #16, 21 and 22, at the tray line with hair coming out of their nets. EI #16's hair was touching the top of her clothing. Some of her hair had broken off and was on the back of her top. EI #17, hair was hanging out at the back of her hair net. On 05/10/18 at 1:33 p.m., the surveyor conducted an interview with EI #17. EI #17 was asked who should wear hairnets. EI #17 replied, every body in the kitchen. EI #17 was asked, when should a hairnet be worn. EI #17 replied, anytime in the kitchen, and around the food production area. EI #17 was asked how should a hairnet be properly worn. EI #17 replied, pulled down with the hair pulled in. EI #17 was asked what was the problem with hair hanging out of the net. EI #17 replied, it had the potential for hair to fall into the food. EI #17 was asked was there hair on the back of a worker's clothing. EI #17 replied, yes. EI #17 was asked which dietary workers hair was not completely enclosed within their hairnet. EI #17 replied, EI #16, 21 and 22.",2020-09-01
87,HATLEY HEALTH CARE INC,15023,300 MEDICAL CENTER DRIVE,CLANTON,AL,35045,2018-05-10,814,F,0,1,YKK111,"Based on observation, interview and a review of the (YEAR) Food Code U.S. (United States) Public Health Service FDA (Food and Drug Administration), the facility failed to ensure the dumpster lid was closed. This was observed on 05/10/18. This has the potential to affect all 132 residents residing in the facility. Findings Include: A review of the (YEAR) Food Code, revealed: . 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnables used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors or covers. On 05/08/18 at 5:09 p.m., the surveyor along with (Employee Identifier) EI #23, a dietary aide, toured the outside area of the kitchen. The first dumpster had the lid completely open. The second one had an one inch gap between the lids. On 05/10/18 at 1:03 p.m., an interview was conducted with EI #23. EI #23 was asked what did she observe when going out to the dumpster. EI #23 replied, the first dumpster lid was open. EI #23 was asked what did she observe about the second dumpster. EI #23 replied, it had a space between the lids. EI #23 was asked who was responsible for keeping the dumpster lids closed. EI #23 replied, the first dumpster, the kitchen. EI #23 was asked what did the facility's policy say regarding the dumpster. EI #23 replied, they were suppose to be closed after each use. EI #23 was asked what was the potential harm when the dumpster lid was not closed. EI #23 replied, a racoon or something could get in the dumpster.",2020-09-01
88,HATLEY HEALTH CARE INC,15023,300 MEDICAL CENTER DRIVE,CLANTON,AL,35045,2018-05-10,880,D,0,1,YKK111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of a facility policy titled, Incontinent & (and) Catheter Care, the facility failed to ensure a Certified Nursing Assistant (CNA) washed her hands during glove changes while performing incontinent care for Resident Identifier (RI) #123. This was observed on 05/09/18, and affected RI #123, one of one residents observed for incontinence care. Findings Include: A review of a facility policy titled, INCONTINENT & CATHETER CARE, with a revised date of 04/06/10 revealed: . IV. COMPLETION 1. Wash hands and change gloves as deemed necessary during the procedure to prevent the spread of infection. RI #123 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 05/09/18 at 9:05 a.m., Employee Identifier (EI) #5, a CNA was observed performing incontinent care for RI #123. EI #5 gathered the supplies washed her hands and put on gloves. EI #5 positioned RI #123, loosened the brief and wiped the perineal area of RI #123. EI #5 removed her gloves, picked up a clean brief and put on clean gloves. EI #5 rolled RI #123 to the right side and cleaned the buttock area. EI #5 placed the clean brief under RI #123, and applied moisture barrier cream. EI #5 removed her gloves and put on clean gloves. EI #5 placed a clean pad under RI #123. EI #5 did not wash her hands between glove changes. On 05/10/18 at 8:35 a.m., an interview was conducted with EI #5. EI #5 was asked what was the policy on washing hands during incontinent care. EI #5 replied, wash hands before and after resident care and between glove changes. EI #5 was asked, what should be done when gloves are removed. EI #5 replied, wash hands or use sanitizer. EI #5 was asked if she washed her hands between glove changes. EI #5 replied, no. EI #5 was asked what was the risk when removing gloves during incontinent care and not washing hands. EI #5 replied, cross contamination. On 05/10/18 at 1:20 p.m., an interview was conducted with EI #3, the Registered Nurse (RN)/Infection Control Nurse. EI #3 was asked what was the policy on hand washing hands during glove changes. EI #3 replied, any time going from dirty to clean and any time gloves were visibly soiled. EI #3 was asked if staff should wash their hands with each glove change. EI #3 replied, yes staff should wash their hands or use an alcohol based hand rub. EI #3 was asked what was the harm in the staff not washing their hands between glove changes. EI #3 replied, it spreads infection and it was cross contamination.",2020-09-01
89,SENIOR REHAB & RECOVERY AT LIMESTONE HEALTH FACILI,15024,1600 WEST HOBBS STREET,ATHENS,AL,35611,2020-02-13,550,D,0,1,SQ2Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and review of a facility policy titled, Urinary Catheter Care, the facility failed to ensure Resident Identifier (RI) #84's Foley catheter bag was in a privacy bag and not visible from the hallway on 02/11/20. This deficient practice affected RI #84, one of one resident sampled with a Foley catheter. Findings Include: A review of a facility policy titled, Urinary Catheter Care, with an effective date of 01/16/14, and a supersedes date of 11/01/01, documented: . PR[NAME]ESS: . i) . Bags should be covered to provide privacy. RI #84 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/22/19, assessed RI #84 as having an indwelling catheter. On 02/11/20 at 10:16 a.m., RI #84's Foley urinary catheter bag was observed uncovered, attached to the left lower side of bed. The bag contained clear yellow urine that was visible from the hallway. On 02/11/20 at 12:50 p.m., RI #84's Foley urinary catheter bag was observed uncovered, attached to the left lower side of bed. The bag contained clear yellow urine that was visible from the hallway. On 02/11/20 at 3:39 p.m., the surveyor conducted an interview with Employee Identifier (EI) #8, RI #84's assigned Registered Nurse (RN). EI #8 stated RI #84's Foley catheter bag was not in a privacy bag when she began her shift at 10:00 a.m. EI #8 was asked if the Foley catheter should have had a privacy bag. EI #8 said yes. The surveyor asked EI #8 what was the concern when a resident's Foley catheter bag was not covered. EI #8 replied, invasion of the resident's privacy. On 02/13/20 at 02:04 p.m., the surveyor conducted an interview with EI #10, RN/DON (Director of Nursing). The surveyor asked EI #10 who was responsible for ensuring the Foley catheter bag was covered with a privacy cover for each resident. EI #10 said all clinical staff that are assigned to that unit. EI #10 was asked what was the concern of a Foley catheter bag not being covered. EI #10 said it was a dignity issue. EI #10 further stated, per facility policy, Foley catheter bags should be covered with a privacy cover.",2020-09-01
90,SENIOR REHAB & RECOVERY AT LIMESTONE HEALTH FACILI,15024,1600 WEST HOBBS STREET,ATHENS,AL,35611,2020-02-13,812,F,1,1,SQ2Q11,"> Based on observations, interviews, review of the (YEAR) Food and Drug Administration (FDA) Food Code, and review of the facility's policies titled, General Food Preparation and Handling, General Sanitation of Kitchen, Food Storage, Cleaning Dishes/Dish Machine, Cleaning Instructions: Ovens, Cleaning Instructions: Floors, Tables and Chairs, and Cleaning Instructions: Refrigerators, the facility failed to ensure: 1) seven items in the reach in cooler were discarded on the used by date, 2) the floors in the dry food storeroom were clean from rodent droppings, underneath the shelving, 3) there was not a white substance on a pan observed on the clean rack, 4) open food items in the walk-in freezer were sealed, 5) the interior of the walk-in cooler was clean and dry, 6) the convection oven did not have a heavy build-up of dark black residue inside the oven, 7) a pole with chipping, flaking paint was not hanging directly beside and above a food preparation area, and 8) a frying pan did not have a non-stick coating peeling off. This had the potential to affect 149 of 149 residents receiving meals from the kitchen. Findings include: 1.) A review of a facility policy titled, Food Storage with a date of 2013, revealed: . Procedure: . 13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded. 14. Refrigerated Food Storage: . f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. On 02/11/20 at 08:48 a.m., Employee Identifier (EI) #1, the Dietary Cook, accompanied the surveyor during the initial tour of the kitchen. In the reach-in refrigerator, the surveyor and EI #1 observed the following: (1) two full pans of leftover mechanical soft meatballs-cooked labeled with a use by date of 2/10/20; (2) leftover cooked carrots labeled with a use by date of 2/10/20; (3) mozzarella cheese with a use by date of 1/29/20; (4) leftover cooked English peas labeled with a use by date of 2/10/20; (5) leftover cooked red beans and sausage labeled with a use by date of 2/10/20; (6) chicken base broth- labeled with an opened date of 1/8/20 and no use by date; and (7) beef base broth- labeled with an opened date of 12/25/19 and no use by date. An interview was conducted on 2/11/20 at 8:48 a.m. with EI #1. EI #1 was asked if these items should have been in the reach-in refrigerator. EI # 1 stated no. EI #1 was asked what the potential harm was in the outdated items being left in the refrigerator. EI #1 stated the residents might get food poisoning. EI #1 was then asked what the facility's policy was on dating food placed in the refrigerator. EI #1 stated they date the items with the day they place it in and the day they throw it away. EI #1 said leftovers are good for three days and the chicken and beef base broth are good for one month after opening. 2.) The (YEAR) FDA Food Code included the following: . 6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. A review of a facility policy titled, Cleaning Instructions: Floors, Tables and Chairs, dated 2013, revealed: . Policy: Kitchen and dining room floors . will be kept clean and sanitary. Procedure: 1. Kitchen floors will be swept and cleaned after each meal. A thorough cleaning using a disinfectant will be done at least daily. A review of a facility policy titled, General Sanitation of Kitchen, dated 2013, revealed: .Policy: The staff shall maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. Procedure: 1. Cleaning and sanitation tasks for the kitchen will be recorded. On 2/11/20 at 10:04 a.m., the floor to the dry storage room was observed to have a medium amount of rodent droppings underneath the dry storage shelving. The surveyor asked EI #2, District Support Manager of the kitchen, to sweep out from underneath the dry storage shelving. After EI #2 swept out from underneath the shelving, the surveyor asked EI #2 what it looked like to her. EI #2 stated it was mouse droppings. The surveyor asked EI #2 should the mouse droppings be underneath the shelving in the dry storage room. EI #2 stated no. EI #2 was asked what the potential harm was in the mouse droppings being in the dry storage room. EI #2 stated bacterial infection, diseases, you do not know what they are carrying. During a follow-up interview with EI #2 on 2/12/20 at 08:31 a.m., EI #2 was asked if she could provide the cleaning logs for the dry storage area. EI #2 stated no she could not. On 2/13/20 at 11:19 a.m., EI #2 was asked if she had a record of when staff clean or do deep cleaning. EI #2 stated no, she did not. EI #2 was asked if she should have a record of when staff do any type of cleaning (per facility policy). EI #2 stated yes, to show proof that it has been done, and to follow up with the specific person if it has not been done properly. EI #2 was then asked if the facility policy specified that there should be a record or log for cleaning. EI #2 stated yes. 3.) The (YEAR) FDA Food Code included the following: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces, and Utensils. (A) . EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) . The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. A review of a facility policy titled, Cleaning Dishes/Dish Machine, dated 2013, revealed: . Policy: All . cookware will be washed, rinsed and sanitized after each use. 2. Scrape dishes clean . 3. Rinse dishes thoroughly in the sink, . scrub pots and pans with a non-metallic scouring pad when necessary . On 02/11/20 at 10:19 a.m., an observation was made of a four inch deep large cooking pan. The pan was on the clean dish rack and was noted to have a white, thin substance inside of it. EI #2, District Support Manager of the kitchen, was asked what the pan was used for. EI #2 stated it was used for meat in the oven. EI #2 was then asked if she saw the white substance. EI #2 stated yes. EI #2 was asked if it rubbed off of the pan. EI #2 stated yes. EI #2 said the white substance should not be on the pan. EI #2 was asked what the potential harm was with the white substance inside the pan. EI #2 stated the potential for bacteria being spread if it is not being cleaned and sanitized properly. 4.) A review of a facility policy titled, Food Storage, dated 2013, revealed: . Procedure: .15. Frozen Foods: . c. All foods should be covered . On 2/11/20 at 10:56 a.m., the surveyor observed the following items in the walk-in freezer: a plastic bag of breaded squash opened to air, a box of rolls in a plastic bag opened to air, and a box of pork fritters in a plastic bag opened to air. On 2/12/20 at 8:55 a.m., an interview was conducted with EI #2, Dietary District Support Manager. EI #2 was asked if the breaded squash, rolls and pork fritters should be left opened to air in the freezer. EI #2 stated no, it causes freezer burn. EI #2 was then asked what the potential harm was in these items being left opened to air and not sealed in the freezer. EI #2 stated they are exposed to all kinds of germs and elements coming into contact with them. 5.) The (YEAR) FDA Food Code included the following: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces and Utensils. (C) . NONFOOD FOOD CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other residue. A review of a facility policy titled, Cleaning Instructions: Refrigerators, dated 2013, revealed: .Policy: . Spills and leaks will be cleaned as they are noticed. Procedure: . 8. Spills should be cleaned at the time they occur. On 2/11/20 at 10:56 a.m., the surveyor walked through the walk-in cooler to get to the walk in freezer. A puddle of water was observed in the floor of the walk-in cooler at the entrance to the freezer. EI #2, the Dietary District Support Manager, was asked what the water was from. EI #2 stated the freezer goes through a defrost cycle. On 2/11/20 at 4:01 p.m., the surveyor and EI #4, the Maintenance Supervisor, went into the walk-in cooler. The surveyor observed a small puddle of water in the floor of the walk- in cooler at the door of the entrance to the freezer. EI #4 was asked if he saw the water. EI #4 stated yes, it looks like water. EI #4 was then asked what the water was from. EI #4 stated it may be condensation from the freezer when the door is opened. On 2/12/20 at 7:56 a.m., a puddle of water was observed in the same area of the floor of the walk-in cooler at the entrance of the freezer door. On 2/12/20 at 09:00 AM, an interview was conducted with EI #3, Dietary Manager. EI#3 was asked if she observed the water in the floor in the cooler on 2/11/20 and 2/12/20. EI #3 stated yes. EI #3 was asked should there be water in the floor of the walk-in cooler. EI #3 stated no. EI #3 was asked what the potential harm was in the water being in the floor in the cooler. EI #3 stated bacteria build-up and bugs. EI #3 was then asked who was responsible for making sure there was no water on the walk-in cooler floor. EI #3 stated the Dietary Aides are supposed to clean it out everyday. EI #3 was asked if she could provide the cleaning logs for the walk-in cooler, and EI #3 stated no; they did not have any. 6.) The (YEAR) FDA Food Code included the following: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces, and Utensils. (A) . EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) . The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) . NONFOOD FOOD CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other residue. A facility policy titled, CLEANING INSTRUCTIONS: OVENS, dated (YEAR), revealed: Policy: Ovens will be cleaned as needed . Spills and food particles will be removed after each use. On 2/11/20 at 11:02 a.m., the surveyor and EI # 2, the District Support Manager of the kitchen, observed a thick black substance in the bottom of the convection oven. EI # 2 was asked what the potential harm was with the black substance being in the oven. EI # 2 replied, a fire and the spread of bacteria with food being left in there. 7.) The (YEAR) FDA Food Code included the following: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces and Utensils. (C) . NONFOOD FOOD CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other residue. . Annex 4, Table 2b . Added Chemical Hazards . chemicals used . paint . (5) . Illness and Injury can result in foreign objects being in food. These physical hazards can result from contamination . at many points . within the food establishment. On 2/11/20 at 4:12 p.m. , the surveyor and EI #3, the Dietary Manager, observed a pole with hanging utensils on it located directly over a food preparation area. There appeared to be gray paint peeling/flaking off of the pole. EI #3 rubbed her finger over the pole and the paint came loose. EI #3 was asked what it looked like to her. EI #3 stated it looked like peeling paint, and it should not be there. EI #3 was then asked what the concern was in the peeling paint over the food preparation area. EI #3 stated it could get into the residents' food and cause sickness. 8.) Review of the facility's policy titled General Food Preparation and Handling, dated 2013, revealed: Policy: Food items will be prepared to . keep free of injurious organisms and substances. Procedure: .5. Equipment . b. dishware that has lost its glaze or is chipped or cracked must be disposed of. On 2/11/20 at 4:18 p.m., an eight inch skillet was observed with a non-stick coating peeling off hanging on a rack, ready for use. EI #3, the Dietary Manager, was asked what she observed. EI #3 stated the non-stick coating was peeling off. EI #3 was asked what the concern was in the non-stick coating coming off or peeling off the pan. EI #3 stated it could be a foreign object in the food and could cause stomach pain as well. EI #3 went on to state the skillet should have been thrown away a long time ago.",2020-09-01
91,SENIOR REHAB & RECOVERY AT LIMESTONE HEALTH FACILI,15024,1600 WEST HOBBS STREET,ATHENS,AL,35611,2020-02-13,880,D,0,1,SQ2Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, medical record review, and review of a facility policy titled Hand Hygiene, the facility failed to ensure: 1) a Licensed Practical Nurse (LPN) washed hands or used hand sanitizer after administering Resident Identifier (RI) #213's nebulizer treatment and placing a garbage bag in the medication cart garbage can, prior to reentering RI #213's room to clean RI #213's facemask; and 2) a Certified Nursing Assistant (CNA) washed hands or used hand sanitizer after she emptied RI #105's urinal, prior to exiting RI #105's room. This affected one of four residents observed during medication administration pass and one of one sampled resident for whom a CNA was observed emptying a urinal. Findings Include: A review of a facility policy titled Hand Hygiene, with a date of 7/30/2016, revealed . Hand Hygiene procedures include the use of alcohol-based hand rubs . and handwashing with soap and water . Always perform hand hygiene in the following situations . Before exiting the patient's care area after touching the patient or the patient's immediate environment . after glove removal . 1) RI #213 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/13/20 at 9:04 a.m., the surveyor observed Employee Identifier (EI) #7, a LPN, during medication administration pass for RI #213. EI #7 gave RI #213's nebulizer treatment and placed a plastic garbage bag in the medication cart garbage can. EI #7 did not wash or sanitize her hands prior to reentering RI #213's room. EI #7 then cleaned RI #213's facemask attached to the nebulizer machine, removed her gloves, and did not wash or sanitize her hands prior to exiting RI #213's room. On 2/13/20 at 9:56 a.m., the surveyor conducted an interview with EI #7, a LPN. EI #7 was asked what she should have done after she started RI #213's nebulizer treatment, placed a plastic garbage bag in the medication cart garbage can, and prior to reentering RI #213's room. EI #7 stated she should have washed her hands or used hand sanitizer. EI #7 was asked what she should have done after she removed her gloves after cleaning RI #213's facemask, prior to leaving RI #213's room. EI #7 stated she should have washed her hands or used hand sanitizer. EI #7 was asked what the facility hand washing/hygiene policy stated should be done after a licensed nurse touched a resident's equipment, environment, and prior to leaving a resident's room. EI #7 stated staff should wash hands or use hand sanitizer. EI #7 was asked what would be the concern in not washing hands or using hand sanitizer after a licensed nurse started RI #213's inhalation nebulizer treatment, placed a plastic garbage bag in the medication cart garbage can, and prior to reentering RI #213's room. EI #7 stated it could spread germs to everyone and they could get an infection. EI #7 was asked what would be the concern if a licensed nurse did not wash her hands or use hand sanitizer after she cleaned RI #213's facemask, removed her gloves, and prior to leaving RI #213's room. EI #7 stated it could spread germs to everyone and they could get an infection. EI #7 said she forgot to wash her hands. On 2/13/20 at 11:06 a.m., the surveyor conducted an interview with EI #6, Infection Control Preventionist/Registered Nurse (RN). EI #6 was asked how are the licensed staff trained at the facility on hand hygiene. EI #6 was asked what a licensed nurse should do after after she started RI #213's inhalation nebulizer treatment, placed a plastic garbage bag in the medication cart garbage can, and prior to reentering RI #213's room. EI #6 stated she should have washed her hands or use hand sanitizer. EI #6 was asked what should a licensed nurse have done after she cleaned RI #213's facemask, removed her gloves, and prior to leaving RI #213's room. EI #6 stated she should have washed her hands or used hand sanitizer prior to leaving the room. EI #6 was asked what the facility policy on hand hygiene stated should be done after a licensed nurse touched a resident's equipment, environment and prior to leaving a resident's room. EI #6 stated staff should wash hands or use a hand sanitizer. EI #6 was asked what would be the concern if a licensed nurse did not wash her hands after she started RI #213's inhalation nebulizer treatment, placed a plastic garbage bag in the medication cart garbage can, and prior to reentering RI #213 room. EI #6 stated it could have spread an infection. EI #6 was asked what would be the concern if a licensed nurse cleaned RI #213's facemask, removed her gloves and did not wash her hands prior to leaving the room. EI #6 stated there was a potential to spread an infection. 2) RI #105 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 2/11/20 at 11:49 a.m., EI #9, a CNA, was observed removing soiled gloves after she emptied RI #105's urinal. EI #9 placed her gloves into the trash can and exited the room without washing her hands. An interview was conducted on 2/11/20 at 11:54 a.m EI #9 was asked what she was doing in RI #105's room. EI #9 said, emptying the urinal, and then placed the urinal back on the side of the bed. EI #9 further stated she threw her gloves in the trash can and did not wash her hands before exiting RI #105's room. The surveyor asked EI #9 if she was supposed to wash her hands after emptying the urinal, before exiting the room. EI #9 replied yes, to prevent the spread of germs, cross contamination and break in infection control. On 02/13/20 at 10:19 a.m., an interview was conducted with EI #6, Infection Control Preventionist/RN. EI #6 said staff should wash their hands before and after resident care, including after emptying a urinal. The surveyor asked EI #6 why staff should wash their hands after emptying a urinal. EI #6 replied, to decrease the spread of infection.",2020-09-01
92,SENIOR REHAB & RECOVERY AT LIMESTONE HEALTH FACILI,15024,1600 WEST HOBBS STREET,ATHENS,AL,35611,2018-02-15,554,D,0,1,EZGG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, and review of a facility policy titled RESIDENT SELF ADMINISTRATION OF MEDICATION, the facility failed to ensure Resident #293 was assessed for self-administering nebulizer treatments. This affected one of one resident reviewed for self administration. Findings include: Review of the facility's policy titled RESIDENT SELF ADMINISTRATION OF MEDICATION, updated 10/31/2017, revealed the following: POLICY: Each resident who desires to self-administer medication may be permitted to do so if Facility Interdisciplinary Care-Plan Team has determined that the practice would be safe for the resident and other residents of the facility. 1. The medication self-administration assessment is conducted by the interdisciplinary team . 2. The results of the interdisciplinary team assessment are recorded on the Self-Administration Assessment Form, which is placed in the resident's medical record. Resident #293 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #293's (MONTH) (YEAR) physician's orders [REDACTED]. There were no orders listed indicating Resident #293 could self-administer medications or nebulizer treatments. Review of Resident #293's comprehensive care plans revealed no care plan or approaches addressing self-administration of medications. On 02/14/18 at 9:26 AM, Resident #293 was observed receiving a nebulizer treatment. No staff were present in the room at the time. Resident #293 reached over and turned the machine off while the surveyor was speaking with the spouse; visible nebulizer solution remained in the nebulizer cup. Employee Identifier (EI) #1, Registered Nurse, was interviewed on 02/15/18 at 05:26 PM. When asked which residents she had that could self-administer nebulizer treatments, EI #1 referred to a list she had, and said Resident #293 was one of the ones she had that was able to self-administer nebulizer treatments. EI #1 explained she put the medication in the nebulizer cup, turned on the machine, and placed it on the resident. EI #1 said she sometimes started the treatment then, but other times, if the resident was not ready, she would let them start it when they were ready. When asked what type of evaluation or assessment was done to determine if residents could safely administer their treatments, EI #1 said she was not sure. She was unaware of the facility's policy. EI #1 said there should usually be a note in the chart or an assessment of some kind. EI #1 said it was important to assess residents to determine they could safely self-administer medications to ensure they were competent to do it and do it properly. EI #2, the Director of Nursing, was interviewed on 02/15/18 at 05:49 PM. EI #2 said the facility had not completed a self-administration assessment on Resident #293. EI #2 further explained the nurse had started the nebulizer treatment, left the resident while it was going, then came back. When asked about the facility's policy on administration of nebulizer treatments, EI #2 said they did not have one. EI #2 stated if a resident was going to self-administer medications, it should be addressed in their care plans, and an evaluation should be completed quarterly or with a significant change in the resident's status.",2020-09-01
93,SENIOR REHAB & RECOVERY AT LIMESTONE HEALTH FACILI,15024,1600 WEST HOBBS STREET,ATHENS,AL,35611,2018-02-15,690,D,0,1,EZGG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of incontinent care on 02/14/18, medical record review, staff interviews, and review of facility policies titled Urinary Catheter Care, and a facility document titled Perineal/Catheter Care, the facility failed to ensure the Certified Nursing Assistant (CNA) properly cleaned Resident #33's catheter tubing. Further, the CNA failed to clean Resident #33's perineal area of fecal matter, prior to the completion of care. These failures were observed during one of one catheter and incontinence care observations. Findings Include: A review of a facility policy titled: Urinary Catheter Care with an effective date of (MONTH) 16, 2014 documented: . PURPOSE: Urinary catheter care helps to prevent urinary tract infection . PR[NAME]ESS: . II. Catheter Care . c) Wash the catheter itself by holding on to the catheter at the insertion site; wash with one stroke downward . A review of a facility document titled: . Perineal/Catheter Care . with a date of 12/18/16 documented: . CATHETER CARE . 2 . Gently . to expose meatus . A review of RI #33's Quarterly Minimum Data Set with an assessment reference date of 11/22/17 revealed RI #33 was severely impaired in cognition, incontinent of bowel and dependent upon staff for hygiene. A review of the hospital DISCHARGE SUMMARY dated 01/04/2018 documented: . DISCHARGE Diagnosis: [REDACTED]. RI #33 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/14/2018 at 5:45 p.m., Certified Nursing Assistant, Employee Identifier (EI) #7 provided incontinent care for RI #33. The resident rolled his/her self to left side and EI #7 wiped the buttock area three times front to back, using a clean wash cloth with each wipe. Bowel movement was visible on each wash cloth used. RI #33 had a foley catheter in place. EI #7 then cleaned the catheter tubing toward the residents perineum. RI #33 rolled onto his/her back. Without changing the soiled gloves or washing her hands, EI #7 then placed a clean brief under RI #33 and put a clean gown on the resident. EI #7 wiped down the left side of the outer perineal area and across. EI #7 then wiped down the right outer perineal area and across. EI #7 fastened the brief, removed the (soiled) gloves and without washing her hands, she applied clean gloves. At the completion of care, the surveyor asked EI #7 if she had visualized the perineal area. EI #7 said no. EI #7 then unfastened the brief, separated the perineal area, and wiped front to back three additional times (using a clean wash cloth each time). Additional bowel movement was apparent on the wash cloth each time. On 02/14/2018 at 6:00 p.m., EI #7 was asked which direction had she wiped the catheter. EI #7 said, she had wiped (incorrectly) back to front (from the residents perineum down the catheter tubing), and she should not have because of contamination. EI #7 was asked why it was important to ensure all bowel movement was removed from the perineal area. EI #7 explained it was necessary to avoid infection and skin breakdown. When asked if she had washed her hands after changing the soiled gloves, EI #7 said no. EI #7 said she should have changed the gloves, due to contamination. EI #7 was asked if she should she have handled the clean brief, clothes and clean linen with soiled gloves. EI #7 said no, due to the contamination of those items. On 02/15/2018 at 5:37 p.m., an interview was done with EI #2, the Director of Nursing/Infection Control. EI #2 stated the staff should wash their hands after taking off soiled gloves and before putting on clean gloves in order to prevent the spread of infection. EI #7 said staff should never touch clean items/linen with soiled gloves so as to prevent the spread of infection. EI #7 was asked what was the facility's policy on catheter care. EI #7 said staff were to wipe front to back, and always visualize the perineal area because you do not want germs near the urinary tract.",2020-09-01
94,SENIOR REHAB & RECOVERY AT LIMESTONE HEALTH FACILI,15024,1600 WEST HOBBS STREET,ATHENS,AL,35611,2018-02-15,803,D,0,1,EZGG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of the facility's policy titled FOOD PREFERENCES, the facility failed to ensure Resident #117 was served foods in accordance with his/her assessed preferences. This affected one of 132 residents for whom meals were observed. Findings include: Review of the facility's undated policy titled FOOD PREFERENCES revealed the following: POLICY: Information will be gathered upon admission to inform the dietary department of the resident/patient's food preferences and diet history. PR[NAME]EDURE: 1. Interview the resident for the following information: . *Food preferences, intolerances, allergies [REDACTED]. Resident #117 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/14/18 at 12:00 PM, Resident #117 was observed eating the lunch meal. Resident #117 said he/she was not supposed to get any fried foods but did so today. The tray card on Resident #117's lunch tray listed fried foods as a dislike. Resident #117's family member (also present) stated he/she could not eat the fried french fries or fried macaroni bites the facility had provided on the tray. On 02/14/18 at 12:20 PM, Employee Identifier (EI) #3, Certified Nursing Assistant, was asked who was responsible for making sure residents received items in accordance with their likes/dislikes. EI #3 stated the dietary department was responsible. EI #3 verified Resident #117 had received fried foods on his/her tray. On 02/15/18 at 06:52 PM, EI #4, the Certified Dietary Manager, explained the Dietary staff list residents' likes and dislikes on their tray tickets and keep each resident's preferences on file in the computer. When asked what system was in place to ensure the items listed on the tray tickets under likes and dislikes were honored, EI #4 said the cooks or person plating the trays read the tickets. EI #4 explained dietary staff were supposed to look at the preferences and, if a resident had a dislike listed, they were not supposed to put it on the tray. EI #4 said it was important to follow residents' preferences for foods because that was what the resident wanted, either for a medical reason, or allergy. EI #4 further stated you want to honor what the resident wants and what they like to eat. EI #4 confirmed the potato wedges (french fries) and macaroni bites were fried. EI #4 said she could not say what happened with Resident #117's lunch tray, but indicated they must have misread the ticket. EI #4 further said the error should not have occurred.",2020-09-01
95,SENIOR REHAB & RECOVERY AT LIMESTONE HEALTH FACILI,15024,1600 WEST HOBBS STREET,ATHENS,AL,35611,2018-02-15,812,F,0,1,EZGG11,"Based on observations, interview of the Certified Dietary Manager (CDM), Employee Identifier (EI) #4, and a record review of the Food Code U.S. Public Health Service (USPHS) and FDA (Food and Drug Administration) 2013, the facility failed to assure: 1. adequate immersion time for food preparation equipment sanitized in hot water which measured 175 degrees Fahrenheit (3-compartment sink). 2. effective cleaning/sanitizing of utensils and equipment to prevent the potential growth of foodborne organisms, a. assure dinnerware, sectional plates, was cleaned to sight/touch (machine dishwashing) and air dried, b. assure equipment, a Tea Urn/spigot a non Time/Temperature control for safety, was cleaned every 24 hours. The spigot was observed with a brown solid build-up, 3. the dishmachine, which sanitizes with chemical, maintained chemical efficacy, by testing, monitoring/documenting the concentration prior to use, These failures had the potential to affect all 132 residents receiving meals from the facility's kitchen. Findings include: 1. Review of the 2013 Food Code by the United States Public Health Service (USPHS) and the Food and Drug Administration (FDA) included the following: 4-7 SANITIZING OF EQUIPMENT AND UTENSILS METHODS 4-703.11 Hot Water and Chemical: After being cleaned .shall be SANITIZED in: (A) Hot water manual operation by immersion for a least 30 seconds and as specified under . 02/13/2018 @7:00 PM, manual dishwashing (pots/pans) was observed. Water in 3rd sink (sanitizing) temperature was measured by the CDM (EI #4), to be 175 degrees F. The employee was observed to dip a washed pot in and out of the hot water, while holding the handle. (For sanitizing, item must remain in hot water 170 or above and less than 180 degrees F. for 30 seconds.) After the above observation, the CDM (EI #4), was asked, why staff failed to leave the item in the hot water for 30 seconds. The CDM responded by saying she could not answer but knows better. 2. (a) Review of the 2013 Food Code by the United States Public Health Service (USPHS) and the Food and Drug Administration (FDA) included the following: 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch . and 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried . On 02/14/2018 at 10:15 AM, an observation was made of clean/sanitized sectional plates stored at the trayline. Seven sectional plates were stacked (not inverted). One of the seven contained water and one contained debris. An interview at this time with the CDM, (EI #4) revealed the first line aide failed to monitor dishes for adequate cleaning. EI #4 was asked what was the potential risk for failure to monitor. EI #4 responded, that there was a potential for food borne illness or bacterial growth. (b) A review of the 2013 Food Code by the United States Public Health Service (USPHS) and the Food and Drug Administration (FDA) included the following: Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned: (E) .surfaces of UTENSILS and EQUIPMENT contacting food that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cleaned: .(2) At least every 24 hours for iced tea dispensers . An observation on 02/13/2018 at 6:50 PM was made of a 5 gallon Tea Urn container. A request was made for the CDM (EI #4) to disassemble the faucet/spigot assembly. The CDM (EI #4) broke the faucet down from the dispenser. The plastic faucet seat was observed to have a brown build-up. The CDM (EI #4) was asked if there was a brown build-up. The CDM (EI #4) acknowledged a build-up. The CDM (EI #4) was asked, what was the potential risk. The CDM (EI #4) responded by saying there was a potential for cross contamination. 3. Line staff failed to monitor/document the chemical sanitizer on (MONTH) 11 and 12. This discrepancy was evidenced by reviewing the facility's document titled, LOW TEMPERATURE DISH MACHINE MONITORIN[NAME] An observation on 02/13/18 at 6:14 PM, during the initial kitchen tour, operation of the dishmachine was made. The sanitizing method in use was chemical (chlorine). The (MONTH) (YEAR), monitoring log for the dishmachine was located in the CDM's (EI #4's) office. A review of the monitoring data revealed omissions for (MONTH) 10 & 11 @ noon meals. On 02/13/2018 at 7:02 PM the CDM (EI #4), was interviewed and asked, why the data was missing. The CDM (EI #4) responded by saying she has not kept track and has a few trainees. The CDM (EI #4) was asked, what are the risk factors for a failure to monitor chemical concentration. The CDM (EI #4) responded by saying there is a potential for bacterial contamination.",2020-09-01
96,SENIOR REHAB & RECOVERY AT LIMESTONE HEALTH FACILI,15024,1600 WEST HOBBS STREET,ATHENS,AL,35611,2018-02-15,880,D,0,1,EZGG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of incontinent care on 02/14/2018 and medication administration on 02/13/2018, a review of the facility's policy's titled Urinary Catheter Care and Hand Hygiene, as well as staff interviews, the facility failed to ensure: 1) A Licensed Practical Nurse (LPN) did not place her ungloved fingers inside medication crush pouches to empty the crushed medications for administration of Resident #58's medications: [REDACTED] 2) A Certified Nursing Assistant (CNA) failed to wash her hands after removing soiled gloves and before putting on clean gloves during the provision of incontinence care. The CNA then touched clean items, including linens and Resident Identifier (RI) #33's clean brief and gown. These failures affected one of four nurses observed during medication pass observations and one of one incontinent care observations, involving RI #58 and RI #33. Findings Include: A review of Potter and Perry, Ninth Edition: FUNDAMENTALS OF NURSING Chapter 32 Medication Administration, page 656, documented: . (1) . Do not touch medication with fingers. (2) To prepare unit-dose tablets . place tablet . directly into medicine cup . A review of a facility policy titled: Hand Hygiene with a date of 07/30/16 documented: . 2. Indications for Hand Hygiene Always perform hand hygiene in the following situations: . After glove removal . 1) RI #58 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #58's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 12/11/17 revealed RI #58 was severely impaired in cognition (with a Brief Interview for Mental Status score of 4 of a possible 15). On 02/13/18 at 7:10 p.m., LPN/Employee Identifier (EI) #6 administered medication to RI #58. EI #6 placed [MEDICATION NAME] 20 milligram (1 tablet) in a crush pouch and crushed the medication. EI #6 opened the pouch with her ungloved fingers and emptied the medication into a medication cup. EI #6 placed [MEDICATION NAME] 50 mg (1 tablet) in a crush pouch and crushed the medication. EI #6 opened the pouch with her ungloved fingers and emptied the medication into medication cup. On 02/13/18 at 7:23 p.m., an interview was conducted with EI #6. EI #6 was asked what did she do when opening the medication pouch. EI #6 explained she had put her bare fingers in the pouch and should have put a glove on, to prevent contamination. On 02/15/2018 at 5:37 p.m., an interview was conducted with the Director of Nursing/Infection Control Director, EI #2. EI #2 was asked why should staff not use ungloved fingers to open a medication crush pouch. EI #2 responded, to prevent cross contamination. 2) RI #33 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #33's Quarterly MDS with a ARD of 11/22/17 revealed RI #33's BIMS score of 2, indicating severe cognitive impairment, dependent upon staff for toileting and hygiene needs, and incontinent of bowel function. RI #33's hospital DISCHARGE SUMMARY dated 01/04/18, documented: . DISCHARGE Diagnosis: [REDACTED]. On 02/14/18 at 5:45 p.m., Certified Nursing Assistant, EI #7 provided incontinent care for RI #33 in the presence of the surveyor. RI #33 rolled to the left side of the bed, EI #7 wiped the buttock area three times front to back, using a clean wash cloth with each wipe. Bowel movement was visible on the wash cloth after each wipe. EI #7 wiped RI #33's catheter tubing, after which RI #33 rolled self onto his/her back. Without removing her dirty gloves, washing hands and changing gloves, EI #7 then placed a clean brief under RI #33 and put a clean gown on the resident. On 02/14/18 at 6:00 p.m., the surveyor asked EI #7 if she had washed her hands or changed soiled gloves. EI #7 said she had not, but she should have, due to contamination. When asked if she should have handled the clean brief, clothes and clean linen with soiled gloves, EI #7 replied, no because of contamination to the items. On 02/15/18 at 5:37 p.m., an interview was done with EI #2, the DON and Infection Control director. EI #2 said staff should wash hands after taking off soiled gloves and before putting on clean gloves to prevent the spread of infection. EI #7 said staff should never touch clean items/linen with soiled gloves to prevent the spread of infection.",2020-09-01
97,SENIOR REHAB & RECOVERY AT LIMESTONE HEALTH FACILI,15024,1600 WEST HOBBS STREET,ATHENS,AL,35611,2019-03-20,812,F,0,1,ITMZ11,"Based on observation, interview and review of facility policies titled, FOOD STORAGE, CLEANING DISHES/DISH MACHINE AND CLEANING INSTRUCTIONS OVEN, the facility failed to ensure: 1. a plastic bag of riblets in the refrigerator was labeled with a date and use by date, 2. staff air dried sectional plates; and 3. the main baking oven was free of a thick black substance. This had the potential to affect 128 of 128 residents receiving meals from the kitchen. Findings Include: A review of a facility policy titled, FOOD STORAGE, with a 2013 date revealed: PR[NAME]EDURE: . 14. Refrigerated Food Storage: . f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates . A facility policy titled, CLEANING DISHES/DISH MACHINE with a 2013 date revealed: PR[NAME]EDURE: . 9. Allow the dishes to air dry on the dish racks. A facility policy titled, CLEANING INSTRUCTIONS: OVENS with a (YEAR) date revealed: Policy: Ovens will be cleaned as needed . Spills and food particles will be removed after each use. 1. On 3/18/19 4:56 PM a plastic double sealed bag, labeled riblets, was observed in the walk in refrigerator. No date or use by date was on the bag. The surveyor asked Employee Identifier (EI) #3, Dietary Manager what was in the bag. EI #3 replied, riblets. EI #3 was asked where was the date or use by date. EI #3 replied, it did not have one. EI #3 was asked if the riblets should be labeled with the use by date. EI #3 replied, yes. EI #3 was then asked why should it have a use by date. EI #3 replied because it was opened, so you will know when it was opened and it does not make anyone sick. 2. On 3/18/19 at 5:55 PM, the surveyor observed, during tray line, a divided plate with water on the inside of the plate in two sections. EI # 3 stated she observed the water on the inside of the divided plate in two compartments as well. EI # 3 was asked should there be water droplets on the plate. EI # 3 replied, no, it should be air dried completely to prevent bacteria growth. 3. On 3/18/19 at 5:59 PM, the surveyor and EI # 3 observed a thick black substance in the main baking oven. The surveyor asked EI # 3 should there be a black substance there. EI # 3 replied no it should be cleaned out and scrubbed. EI # 3 was then asked what was the potential harm with the black substance being in the oven. EI # 3 replied, because it could catch on fire.",2020-09-01
98,SENIOR REHAB & RECOVERY AT LIMESTONE HEALTH FACILI,15024,1600 WEST HOBBS STREET,ATHENS,AL,35611,2019-03-20,880,D,0,1,ITMZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of a facility policy titled, Dressing - Clean, the facility failed to ensure staff gloves were removed and hand hygiene was performed after cleaning a sacral wound and before applying ointment and touching other parts of the resident's body, pillow, blanket and bed remote. This affected Resident Identifier (RI) #65, one of 2 residents observed for wound care. Findings include: A facility policy titled, Dressings-Clean, with an effective date of (MONTH) 1, 2001, revealed: . Process: . 13. Remove gloves and wash hands. A facility policy titled, Hand Washing, with an effective date of (MONTH) 1, 2001, revealed: . Standard: Hand washing should be performed between procedures with residents. RI #65 was readmitted to the facility on [DATE] with two sacral ulcers. [DIAGNOSES REDACTED]. Review of the resident's physician's orders [REDACTED]. On 03/19/19 at 10:14 am, the surveyor observed pressure ulcer care provided by Employee Identifier(EI) #2, the facility Certified Registered Nurse Practitioner, and EI #4 Registered Nurse/Wound Nurse, to RI #65. EI #2 was observed to remove the dressing to the sacral area and discarded it into the trash container. She then discarded the gloves into the trash container, washed her hands in the bathroom sink and applied new gloves. EI #4 stated this was a new wound area from around the (MONTH) 15 th, 2019. EI #2 cleaned the sacral area wound with normal saline applied to folded gauze handed to her by EI # 4. EI#2 then wiped the wound on the sacral area with the gauze. EI #2 proceeded to touched the resident on the gown with the same gloved hand. EI #2 applied [MEDICATION NAME] powder mixed with Venalex ointment from a medicine cup with a Q-tip. After applying the ointment EI #2 then touched RI #65's pillow under the resident's head, the resident's arm and then the blanket lying on the bed, pulling it up over RI #65's, wearing the same soiled gloves. EI #2 picked up the bed remote, operated it lowering the bed and touched the resident's left upper arm. EI #2 then removed the gloves and threw them in the trash container. On 03/19/19 at 01:40 pm, the surveyor interviewed EI #2. She was asked what should she do in between wound care and contact with other items in the resident's room. EI#2 replied she should remove the gloves and wash her hands if it is contaminated. EI #2 was asked did she touch other items in the residents room with the same gloves on after she cleaned the sacral wound with the saline gauze and applied ointment. EI#2 replied she did, but her hand was not contaminated. EI #2 was asked after caring for the wound, what items in the resident's room did she touch with those same gloves on. EI#2 replied she touched the patient, the bed linens, and she touched the resident's bed control. She said it was not a draining wound and she never came in contact with the wound bed. The surveyor asked what was the potential harm when you are caring for a wound and then touch other items in the room with the same gloves on. EI #2 responded, that could be contamination and cross contamination if the gloved hand was contaminated. On 03/19/19 at 04:40 pm, the surveyor interviewed EI #1, Assistant Director of Nursing. EI #1 was asked what should staff do after cleaning and applying ointment to a sacral wound before touching other objects in a resident's room. EI #1's response was they should take the gloves off, dispose of them properly and wash their hands properly. The surveyor asked what was the potential harm for using the same gloves worn to clean a wound and apply ointment and then touching the pillow under the resident's head. EI #1 replied you have a potential to spread germs.",2020-09-01
99,"WETUMPKA HEALTH AND REHABILITATION, LLC",15027,1825 HOLTVILLE ROAD,WETUMPKA,AL,36092,2017-02-23,325,D,0,1,6GSS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and a review of a facility policy titled Therapeutic Supplements, the facility failed to ensure RI (Resident Identifier) # 14 a resident at risk for weight loss received a magic cup as ordered with the lunch and dinner meal on 2/22/17. This affected one of 12 sampled residents who were observed for meals on 2/22/17. Findings Include: A review of a facility policy titled, Therapeutic Supplements with an effective date of (MONTH) 13, 2013 documented the following: .PURPOSE: Residents may require supplementation of their meal plan in order to attain or maintain acceptable parameters of nutrition . RI #14 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #14's weight change history documented the following: .9/6/16 Weight 89lbs (pounds) 10/4/2016 Weight 94lbs, 11/10/2016 Weight 94lbs, 12/10/2016 Weight 90lbs, 1/3/2017 Weight 90lbs, 2/7/2017 Weight 97lbs and 02/14/2017 Weight 96lbs. A review of RI #14's Departmental Notes documented the following: .2-15-2017 RD NOTE REVIEWED. MAGIC CUP ADDED AT LUNCH AND DINNER AS RESIDENT WILL ALLOW . A review of RI # 14's Physician order [REDACTED].MAGIC CUP WITH LUNCH AND DINNER AS RESIDENT WILL ALLOW . Meal observations: On 2/22/17 at 11:25 a.m. RI #14's lunch meal was observed. RI #14 received a pureed meal to include ham, cabbage, butterbeans, cornbread and pie. No magic cup was observed on the tray. The meal was completed at 11:50 a.m. On 2/22/17 at 5:00 p.m. RI #14's dinner meal was observed. RI #14 received a pureed meal to include potatoes/gravy, meat, okra, bread and dessert. No magic cup was observed on the tray. The meal was completed at 5:30 p.m. On 2/23/17 at 9:50 a.m., an interview was conducted with EI (Employee Identifier) # 3, Dietary Manager. EI #3 was asked if RI #14 was supposed to receive a magic cup with lunch and dinner. EI #3 responded as of (MONTH) 15th according to the medical order. EI #3 was asked why the magic cup was ordered. EI #3 responded probably for weight maintenance. EI #3 was asked who was responsible for ensuring a magic cup was served with lunch and dinner. EI #3 responded the kitchen would be responsible for putting it on the tray. EI #3 was asked what was the harm of RI #14 not receiving a magic cup as ordered. EI #3 responded RI #14 would lose the calories. On 2/23/17 at 10:10 a.m., an interview was conducted with EI #6, Registered Dietitian. EI #6 was asked if RI #14 was supposed to receive a magic cup with lunch and dinner. EI #6 responded it was a recommendation she made on 2/13/15. EI #6 was asked why the magic cup was recommended. EI #6 responded RI #14's recent intake had been inconsistent so a supplement was suggested at lunch and supper. EI #6 was asked who was responsible for ensuring the magic cup was placed on the tray. EI #6 responded the dietary manager or myself. EI #6 was asked if RI #14 was at risk of weight loss. EI #6 responded yes because of inconsistent intake. On 2/23/17 at 10:20 a.m., an interview was conducted with EI #7, Registered Nurse (RN). EI # 7 was asked if she completed the order for a magic cup for RI #14. EI #7 responded yes on 2/15/17. EI #7 was asked if RI #14 should have started receiving the magic cup on 2/15/17. EI #7 responded it was late in the day so it would have started on 2/16/17. EI #7 was asked why the magic cup was ordered for RI #14. EI #7 responded he/she had lost one pound and we added it to ensure he/she did not lose anymore weight. EI #7 was asked if RI #14 should have received a magic cup on 2/22/17 with lunch and supper. EI #7 responded yes.",2020-09-01
100,"WETUMPKA HEALTH AND REHABILITATION, LLC",15027,1825 HOLTVILLE ROAD,WETUMPKA,AL,36092,2017-02-23,371,F,0,1,6GSS11,"Based on observations, interviews, record reviews and a review of facility policies titled Food Receipts and Storage and Food Cooking and Serving Temperatures, the facility failed to ensure a can was not dented, a can was labeled in dry storage and milk temperatures were written down on the menu daily. This had the potential to affect 115 of 116 residents who receive meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Food Receipt and Storage with an effective date: of (MONTH) 21, 2013 revealed: .PR[NAME]ESS I. Receiving Foods: .b. all items delivered should be checked as follows: Cans are intact, free of dents, . II. Storage of Foods: .f. Place dented .cans .in a separate area . On 2/21/2017 at 2:05 p.m., the surveyor along with the dietary manager toured the dry storage area in the kitchen. The surveyor observed a six pound can of pineapple tidbits with a dent at the top and bottom of the can. On 2/23/2017 at 9:01 a.m., the surveyor conducted an interview with (Employee Identifier ) EI #3, dietary manager. EI #3 was asked what can in dry storage was dented. EI #3 replied, pears and changed her answer to pineapple tidbits. EI #3 was asked where was the can dented at. EI #3 replied, on the side. EI #3 was asked what was the facility policy on dented cans. EI #3 replied, place in the dented cans location. EI #3 was asked where was the can located in dry storage. EI #3 replied, in with regular cans. EI #3 was asked who was responsible for removing dented can from the regular can area. EI #3 replied, she was and staff. EI #3 was asked why was the dented can in with regular cans. EI #3 replied, it was overlooked. EI #3 was asked why should dented can foods not be cooked. EI #3 replied, an infection control issue, it can mess up what was inside and they can not use something once air gets inside. On 2/23/2017 at 9:33 a.m., an interview was conducted with EI #4, dietary aide. EI #4 was asked who was responsible for putting supply items away. EI #4 replied, he was and another worker. EI #4 was asked what was the facility policy on dented cans. EI #4 replied, put on the dented can shelf. EI #4 was asked who was responsible for removing dented cans from regular can area. EI #4 replied, the person who was putting up the stock that day. 2) A review of a facility policy titled, Food Receipt and Storage with an effective date of (MONTH) 21, 2013 revealed: .II. Storage of Foods: . k. open food items should be . labeled, and dated . On 2/21/2017 at 2:05 p.m., the surveyor observed a container of opened creamy peanut butter with no open or use by date. On 2/23/2017 at 9:11 a.m., an interview was conducted with EI #3. EI #3 was asked what label was on the peanut butter. EI #3 replied, the date it came in. EI #3 was asked was the peanut butter opened. EI #3 replied, yes ma'am. EI #3 was asked was there a use by date on it. EI #3 replied, no ma'am. EI #3 was asked why was there no label on the container. EI #3 replied, they did not put a date on it. EI #3 was asked what was the facility policy regarding opened food items. EI #3 replied, anything opened must have a date on it. EI #3 was asked who was responsible for labeling food items that had been opened. EI #3 replied, any staff that open it. EI #3 was asked when should a label be placed on opened food items. EI #3 replied, when it was first open. EI #3 was asked what was the potential harm when food items were opened and there was no open or use by date on the container. EI #3 replied, it could go out of date and not be good. EI #3 was asked what was the opened date on the container. EI #3 replied, there was not one. 3) A review of a facility policy titled, Food Cooking and Serving Temperatures with an effective date: (MONTH) 25, 2012 revealed: .PURPOSE: Safe and sanitary food handling practices include effective control of food temperatures, in order to prevent food borne illnesses .PR[NAME]ESS: I. Food Cooking Temperatures: b. The temperature of foods should be taken and recorded immediately . III. General Guidelines: . b. Food temperatures should be recorded on the menu . On 2/22/2017 at 10:50 a.m., the surveyor observed the milk box opened while staff was plating and there was no staff member writing down the milk temperature on the menu. The surveyor reviewed other menus for the month of (MONTH) and there were several days the milk temperatures was not recorded. The milk temperatures were not recorded for (MONTH) 12,13,14,15,16, 17, 18, 19, 20, and 21 of (YEAR). On 2/23/2017 at 9:19 a.m., an interview was conducted with EI #3. EI #3 was asked when was the temperature of the milk taken. EI #3 replied, before the line started. EI #3 was asked where was it documented that it was taken. EI #3 replied, it was not documented. EI #3 was asked why was it not documented. EI #3 replied, staff forgot to write it down on the menu. EI #3 was asked who was responsible for taking the temperature of the milk. EI #3 replied, dietary aide. EI #3 was asked what was the facility policy on taking milk temperatures before serving milk to the residents. EI #3 replied, take the temperatures and document. EI #3 was asked how do you know temperatures were taken if they did not write it down. EI #3 replied, they did not know. EI #3 was asked were milk temperatures written down for (MONTH) 12, 13,14, 15, 16, 17, 18, 19, 20, and 21 of (MONTH) (YEAR). EI #3 replied, no ma'am to all days. On 2/23/2017 at 9:28 a.m., an interview was conducted with EI #4. EI #4 was asked when was the temperature of the milk taken. EI #4 replied, around ten minutes to ten. EI #4 was asked where was it documented. EI #4 replied, he did not document it. EI #4 was asked why was it not documented. EI #4 replied, it slipped his mind. EI #4 was asked who was responsible for taking the temperatures of the milk. EI #4 replied, he was when working. EI #4 was asked what was the facility policy on taking milk temperatures before serving to the residents. EI #4 replied, temperatures should be 41 degrees and below and make sure it was documented. EI #4 was asked how do anyone know if temperatures were taken if it was not written down. EI #4 replied, he normally mention the temperature to the person writing food temperatures down. EI #4 was asked was the milk temperatures written down for (MONTH) 12, 13, 14, 15, 16, 17, 18, 19, 20, and 21 of (MONTH) (YEAR). EI #4 replied, no ma'am for all days. On 2/23/2017 at 9:41 a.m., an interview was conducted with EI #5, dietary aide. EI #5 was asked who was responsible for taking the temperatures of the milk. EI #5 replied, dishwashers and dietary aides. EI #5 was asked was the milk temperature written down for (MONTH) 12, 13, 14, 15, 16, 17, 18, 19 and 20 of (MONTH) (YEAR). EI #5 replied no ma'am for all days. EI #5 was asked how do anyone know if he took milk temperature if he did not record it. EI #5 replied, there was no way to tell if you did not document.",2020-09-01