| 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 |