| 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 |