cms_UT: 13
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 13 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2018-01-17 | 880 | E | 0 | 1 | 1JS611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determine for 5 of 30 sampled residents that the facility did not 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. Specifically, a resident was observed to handle the beverage carafes in the dining room and drink from other resident's glasses, a resident was observed to wipe her nose on the dining room table cloths, a residents tube feeding tubing connector was contaminated and reconnected to the resident without being changed, and multiple residents were observed to have a productive cough during dining in the dining room. Resident identifiers: 11, 54, 64, 68, and 73. Findings include: 1. Resident 68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/9/18 at 12:07 PM and at 12:25 PM, an observation was made of resident 68 wiping her nose on the dining room table cloth during the lunch meal. No observation was made of the dining room table linens being changed. Resident 68 was also observed to have a wet productive cough during the lunch meal. On 1/09/18 at 10:43 AM, resident 68 was heard moaning and coughing from hallway. On 1/10/18 at 8:22 AM, an observation was made of resident 68 wiping her nose on the dining room table cloth during the breakfast meal. No observation was made of the dining room table linens being changed. Resident 68 was also observed to have a wet productive cough during the breakfast meal. On 1/9/18, resident 68's electronic medical records was reviewed. Review of the nursing progress notes on 1/2/18 stated, Note Text: Res (Resident) started on [MEDICATION NAME] 75 mg (milligrams) BID (twice a day) x (times) 5 days per MD (Medical Doctor) request for [MEDICATION NAME]. Review of the labs revealed no documentation to indicate that resident 68 was tested for influenza. Review of the temperature summary record revealed the following: a. On 1/3/18 at 10:47 AM, resident 68 had a temperature of 99.1 F (degrees Fahrenheit) b. On 1/7/18 at 10:58 AM, resident 68 had a temperature of 97.7 F c. On 1/11/18 at 1:59 PM, resident 68 had a temperature of 97.7 F Review of the physician orders [REDACTED]. On 1/16/18 10:02 AM, an interview was conducted with the facility Administrator. The Administrator stated that he had his staff change out the table linens as needed and that there was no set schedule. No additional information was provided when he was informed that resident 73 was touching all the beverage carafes during dining. 2. Resident 64 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 1/09/18 at 2:12 PM, an observation was made of resident 64 lying in bed on the left lateral side with the head of the bed elevated 30 degrees. Resident 64's tube feed was running at 145 milliliters per hour (ml/hr.), and was dated 1/8/17 at 2000 (8:00 PM). The tube feed tubing was observed to be disconnected from resident 64 and on the bed sheets behind the resident spilling the formula behind her. On 1/09/18 at 2:52 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the tube feed was not connected when she went into the residents room at 2:24 PM. LPN 1 stated that it was underneath the resident and she moved it while the linens were being changed. On 1/09/18 at 3:28 PM, observed resident 64 to be in bed with the tube feed hooked back up to resident 64's gastrostomy tube. The tubing was observed to be dated 1/8/17 at 2000 (8:00 PM). On 1/16/18 at 12:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the tube feeding bag and tubing was to be changed every 24 hours and as needed if the connector tip was contaminated. The DON further stated that the staff should have changed the bag and tubing after the connector was found unhooked and underneath the resident. 3. Resident 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/10/18 at 8:08 AM, an observation was made of resident 11 coughing in the dining room. At 8:19 AM, an observation was made of resident 11 coughing. Resident 11 was observed to continue to cough throughout the dining observation. On 1/10/18 at 11:02 AM, an observation was made of resident 11 coughing through the lunch meal. Resident 11 was not observed to cover her mouth. Resident 11 stated to staff that she did not feel good. On 1/16/18 at 8:05 AM, an observation was made of resident 11. Resident 11 was coughing throughout the breakfast meal. Resident 11 was not observed to cover her mouth when coughing. Resident 11's medical record was reviewed on 1/11/18. Resident 11's temperature documented in the medical record were: (Note: All temperatures were in degrees Fahrenheit.) a. 1/10/18 99.9 b. 1/9/18 97.9 c. 1/7/18 97.0 d. 1/6/18 98.8 e. 1/5/18 100.0 Resident 11's progress notes revealed the following: a. On 1/3/18 at 6:00 AM, Result received from flu swab on 1/2/18, positive for Influenza [NAME] MD notified of result. [MEDICATION NAME] ordered. b. On 1/6/18 at 11:54 PM, Resident continues [MEDICATION NAME] tx (treatment). poor appetite this shift. supplements offered and refused. c. On 1/6/18 at 6:44 PM, Resident continues on [MEDICATION NAME] tol (tolerated) well no issue or side effects, will continue to monitor for s/s (signs and symptoms) of further flu VS (Vital Signs) WNL (Within Normal Limits). (Note: Resident had a documented temperature on 98.8.) d. On 1/8/18 at 3:11 PM, FLU: Res has finished her [MEDICATION NAME] regimen, no signs of adverse effects noted. Res is still having a lot of lethargy, WCTM (Will Continue To Monitor). On 1/11/18 at 12:04 PM, an interview was conducted with the DON. The DON stated the nurse obtained resident 11's vital signs and listened to her lungs. The DON stated that resident 11 was fine. The DON stated that a fever was 100.3 degrees Fahrenheit but if a resident had a temperature of 99.9 then staff should intervene. 4. Resident 54 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 1/10/18 at 12:36 PM, an observation was made of resident 54 in the dining room. Resident 54 was observed to be coughing during the dining meal. Resident 54 was not observed to cover her mouth when coughing. Resident 54 was observed to cough on other residents meals. On 1/16/18 at 8:20 AM, an observation was made of resident 54 in the dining room. Resident 54 was observed to cough during the meal. Resident 54 was not observed to cover her mouth when coughing. Resident 54 was observed to cough on other residents meals. Resident 54's medical record was reviewed on 1/11/18. Resident 54's progress note dated 1/2/18 revealed, Res started on [MEDICATION NAME] 75 mg BID x 5 days per MD request for [MEDICATION NAME]. 5. On 1/10/18 at 9:08 AM, an observation was made of resident 73 in the secured unit dining room. Resident 73 was observed to touch and pick up carafes with milk and juice. Resident 73 was observed to touch the carafes and replacing the carafes into a container with ice. On 1/10/18 at 9:18 AM, an interview was conducted with Dietary Aide 1. DA 1 stated that the beverages in the carafes were used for 3 days and then discarded. DA 1 stated that the carafes were not washed after each meal. | 2020-09-01 |