| 6561 |
PARK PLACE NURSING FACILITY |
115005 |
1865 BOLD SPRINGS ROAD |
MONROE |
GA |
30655 |
2013-06-27 |
441 |
F |
0 |
1 |
DT4T11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, review of facility policy and staff interviews, the facility failed to ensure that staff washed and/or sanitized their hands prior to serving meal trays in two (2) of two (2) dining rooms, on three (3) of six (6) halls (halls D, E and F) and to ensure that resident's personal hygiene items were properly labeled and stored in two (2) rooms on one (1) hall (B) of six (6) halls, and that six (6) of ten (10) new employees had a [MEDICATION NAME] skin test (PPD) prior to contact with residents and that one (1) of six (6) current contract employees had their annual PPD skin test done timely (SS, TT, UU, V V, XX, YY, LL. The census was one hundred and fifty eight (158). Findings include: 1. Observation of the dining service on the D-hall on 6/24/13 at 12:40 p.m., revealed that Certified Nursing Assistant (CNA) JJ took a tray into a room and placed the tray on a resident's overbed table, then pulled the resident up in the bed, and proceeded to set up the resident's tray, touching a straw. Continued observation revealed the CNA returned to the cart and obtained another tray for another resident without washing and/or sanitizing her hands. During this observation on the D-hall dining service, there was no evidence of hand sanitizer available either in the hallway and/or resident's rooms. Observation of a second meal service on 6/26/13 at 7:45 a.m. in the dependent dining room (Dining room [ROOM NUMBER]) revealed two (2) hand sanitizers available at each end of the dining room. At 7:55 a.m. the Clinical Administrator, who was helping with meal service, took a bowl with a banana peel from a resident's tray to the trash can but did not wash nor sanitize her hands before moving to help the next resident. Continued observation in dining room [ROOM NUMBER] on 6/26/13 at 8:01 a.m. revealed that when one (1) of the two (2) hand sanitizers, the one (1) closest to the outside door was empty. Continued observation on 6/26/13 at at 8:03 a.m. revealed that the Clinical Administrator putting her hands under the empty sanitizer and then continued to assist residents with their trays. Observation on 6/27/13 at 10:00 a.m. in the dependent dining room [ROOM NUMBER] revealed the hand sanitizer remained empty. Interview with the Clinical Administrator on 6/27/13 at 10:05 a.m. revealed that she was not aware the hand sanitizer was empty in the dependent dining room and was not aware she had not washed or sanitized her hands between residents at meal service; however, she was aware this should be done. Review of the facility Handwashing policy revealed that staff are to wash their hands before handling food and feeding residents. 2. Review of the employee files revealed that six (6) of sixteen (16) employee files reviewed revealed that the following employees received a Purified Protein Derivative (PPD) skin test after their date of hire: - CNA TT- date of hire-5/30/13-PPD administered 6/3/13 - CNA SS-date of hire-3/04/13-PPD administered 3/7/13 - CNA UU-date of hire-4/10/13-PPD administered 5/7/13 - Registered Nurse YY-date of hire-3/30/13-PPD administered 4/6/13 - Licensed Practical Nurse (LPN) XX-date of hire-6/13/13-PPD administered 6/15/13 - LPN VV-date of hire-3/09/13-PPD administered 3/10/13 Continued review revealed that Therapy Manager LL received his/her last PPD in April, 2012 but had continued contact with residents. Interview on 6/26/13 at 11:15 a.m. with the Director of Nursing (DON) revealed all new employees should have the results of the their PPD prior to contact with residents. Interview with the Therapy Manager on 6/26/13 at 4:55 p.m., revealed he knows that PPD should be done annually and confirmed that his/her last PPD was completed in April, 2012. 3. Observation on 6/26/13 between 7:52 a.m. and 8:00 a.m. on the E-hall revealed staff CNA AA delivered a breakfast tray to a resident in room E-79, where she raised the head of the resident's bed and assisted the resident with the set-up of the tray. Continued observation revealed that the CNA then got another breakfast tray off the cart and delivered it to room E-74, where she assisted another CNA move the resident up in the bed. CNA AA proceeded to the dining room and started feeding a resident; however, throughout this observation the CNA never washed her hands nor did she use hand sanitizer. Review of the facility Hand Washing policy revealed for employees to wash hands before handling food and feeding residents; before each procedure and/or resident care; and after each procedure and/or resident care. 4. Observation of LPN BB on 06/26/13 at 7:40 a.m., in Dining Room number one (1), revealed that she dropped a clothing protector on the floor, picked it up and placed it in the dirty hamper, then the LPN took a tray from the food cart, took it to a resident and assisted with set up. Continued observation revealed that the nurse opened the milk carton, placed her fingers on the open portion of the milk carton, took the drinking straw cover off and placed it in the milk, touching both ends of the straw with her unwashed, ungloved hands. Further observation revealed that the LPN got another food tray from the cart and proceeded to give to another resident in the dining room, this time touching the rim of the resident's drinking glass with her unwashed hands. 5. Observation of CNA QQ on 6/26/13 at 7:40 a.m., revealed that CNA QQ served the resident in room [ROOM NUMBER] their breakfast tray, then continued to serve other residents trays without washing/sanitizing her hands. Observation of CNA RR on 6/26/13 at 7:40 a.m., revealed that the CNA did not wash her hands between serving and/or setting up breakfast trays for residents in rooms 85, 75 bed A and B and room [ROOM NUMBER]. 6. Observation on 6/24/13 between 11:20 and 11:50 a.m. in room B-18 revealed unlabeled personal items located on the top of a dresser including; one (1) beige cup with pink and blue flowers that contained a four (4) ounce Colgate toothpaste with a blue and white tooth brush, and one (1) white tooth brush holder with green trim and four (4) tooth brush openings with (1) light green tooth brush in the center opening. Continued observation revealed one (1) pink and white toothbrush, and one (1) freshmint, 1.5 ounce, toothpaste also in the white tooth brush holder with the green trim. The room was a semi private room with two residents in the room. Observations on 6/24/13 at 12:20 p.m. and 2:00 p.m., 6/25/13 at 11:00 a.m. and 2:00 p.m., 6/26/13 9:00 a.m. and 1:00 p.m., and 6/2713 at 12:20 p.m. revealed that all of the above concerns remained the same. Interview with the Assistant Director of Nursing (ADON) on 6/27/13 at 12:25 p.m., revealed that all items should be marked with the residents name and confirmed that these items in room B-18 were not labeled and acknowledged that they should have been. |
2017-11-01 |