| 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 |