| 17 |
GREENBRIAR HEALTHCARE |
305005 |
55 HARRIS ROAD |
NASHUA |
NH |
3062 |
2018-03-05 |
908 |
E |
0 |
1 |
6C1411 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview it was found that the facility failed to maintain patient care equipment in safe operating condition to meet residents needs due to 5 of 6's batteries that failed to hold a charge and left 14 residents who are Hoyer lifts from getting care if needed. Also the facility failed to document temperatures of the hydrocllator on a daily bases to prevent burning during resident treatment. (Resident identifier is #90). Findings include: On 2/27/18 at 10:58 a.m. interview with Resident #90 stated they did not get a shower on 2/23/18 due to the Hoyer lift's not working and being able to get them out of bed. On review of the shower schedule for Resident #90 it was found that the information provided was correct and Resident #90 did not get a shower as documented on 2/23/18. Interview with Staff B (LNA) confirmed that none of the Hoyer lifts work due to the batteries not able to hold a charge. Staff B also confirmed that Resident #90 did not get a shower that day due to the lifts not working and also said other residents also did not always get up for the day due to the battery issues. Staff B when on to say that the Hoyer's would work for about 2 seconds and then they would have to find another battery to continue the task. Staff B also stated that lots of times the resident's would get stuck in the middle of transferring them and they would have to physically remove the resident from the Hoyer lift. On review of the facility's Battery Charging Tracking Tool sheet for 2/26/18 it documents that battery #'s (1, 3, 4, 6, and 7) under Comments no good. Observation on 3/1/18 at approximately 9:00 a.m. of the facility rehabilitation area with Staff P (Rehabilitation Director) revealed that the facility hydrocllator log did not have temperatures taken on the following dates: 1/1/18, 2/18/18, 12/25/17, 11/23/17, 10/6 & 10/7/17, 9/2/17, 9/4/17, 9/9/17, 9/16/17, 9/23/17, 9/30/17, 8/5/17, 8/12/17, 8/19/17, 8/26/17. Temperatures were not done on Sundays for the following dates 1/7/18,1/14/18, 1/21/18 and 2/28/18, 2/4/18, 2/11/18, 2/25/18, 12/3/17, 12/10/17, 12/17/17 and 12/24/17,11/5/17, 11/12/17, 11/19/17, 11/26/17 and 10/1/17, 10/8/17, 10/15/17, 10/22/17 and 10/29/17. Review of the facility policy and procedure titled Clinical Practice Guidelines for the [MEDICATION NAME] dated 9.23.14 revealed the following [MEDICATION NAME] Unit Maintenance . The unit water temperature should be checked and recorded on a daily basis. Review of the INSTRUCTIONS FOR THE USE AND OPERATION OF THE [MEDICATION NAME] M-2 MASTER HEATING UNIT revealed the following: PRECAUTIONARY INSTRUCTIONS 3. REMEMBER. the water temperature in the [MEDICATION NAME] is approximately 160 degrees F (71 degrees C) and the water scalding temperature is approximately 120 degrees F (49 degrees C) . The following steps should be taken when applying the Steam Packs. 1. Know and apply the Precautionary rules. They are for the protection of both the patient and the therapist. Interview on 3/1/18 at approximately 9:00 a.m. with Staff P during this observation confirmed that the [MEDICATION NAME] temperatures were not consistently taken as listed in the above findings. Observation on 03/05/18 at 09:55 AM the tiles, on Unit 2 in rooms 16,19,21.18. 22, 23, 24, 25, and 27 are all cracked and are hard to maintain the integrity to the floor. The wallpaper outside rooms 17, 19, 21 and 22 are peeling and or missing. Interview on 2/28/18 at 1:00 p.m. with Staff C (Director of Nursing) we review the Capital budget which has some improvements for the roof, floor and medication room but not the individual floors or replacing the wallpaper. |
2020-09-01 |