| 1920 |
PREMIER ESTATES OF KENESAW, LLC |
285166 |
P O BOX 10, 100 WEST ELM AVENUE |
KENESAW |
NE |
68956 |
2019-09-12 |
600 |
H |
0 |
1 |
WSRR11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (9) Based on observation, interview, and record review; the facility failed to protect the residents from neglect by failing to ensure staff had the supplies needed to care for residents. This had the potential to affect all of the facility residents. The facility identified a census of 52 at the time of survey. Findings are: Interview with MA-O (Medication Aide) on 9/08/19 at 6:18 PM revealed the facility did not have any disposable wipes so they were using paper towels to provide perineal care to the residents as they had been directed. Observation of the facility nursing supply store room on 9/09/19 at 2:38 PM with NA-U (Nurse Aide) and NA-V revealed there were no disposable wipes. NA-U and NA-V both reported this was the storeroom they were directed to retrieve nursing supplies. NA-V revealed they had asked one of the facility staff about the wipes and they were told they had backordered. Interview with NA-U on 9/9/2019 at 2:38 PM revealed the facility never had enough disposable wipes as they frequently ran out of them. NA-U revealed they were told to use wash cloths to provide perineal care but NA-U was uncomfortable doing this as there were no wash cloths designated specifically for perineal cleansing use and NA-U felt they should not be using the same wash cloths for perineal care that the staff used to wash the residents' faces, etc. Interview with HS (Housekeeping Supervisor) on 9/11/19 at 2:27 PM revealed they were responsible for ordering nursing supplies. HS revealed there was one case of disposable wipes located in the facility. Someone had put them in the wrong storeroom. HS did not confirm or deny the facility ran out of supplies or if the storeroom was being checked regularly to ensure there were ample supplies. Review of the facility policy Central Supply issued (MONTH) 20, 2019 revealed the following: The purpose of the central supply system is to: Maintain Inventory Control. B. Observation of the facility on 9/12/19 at 12:26 PM revealed none of the residents had any hand towels or washcloths. Interview with MA-D on 9/12/19 at 12:31 PM revealed the nursing staff were supposed to pass linen at least once a shift. MA-D revealed they did not know why the residents did not have towels and washcloths. MA-D revealed they knew the facility had been low on them and they have been trying to get some more ordered. C. Interview with Resident 1 on 09/09/19 at 1:53 PM revealed it had been hot in the facility most of the summer. Interview with the MS on 9/11/2019 at 2:27 PM confirmed the AC (Air Conditioner) had not been working during the first part of the summer. It took 3 years to get fixed. The MS revealed 4 AC units had been down at one time. D. Interview on 9/09/19 at 10:07 AM with Resident 42 revealed the resident had not had a bath in the past year at times for weeks at a time. Right now the thing that really concerned the resident was during the whirlpool baths the staff were not turning on the whirlpool jets because they could not clean the jets properly because the facility was out of the proper disinfectant they needed to clean the jets in the tub. Interview on 9/10/19 at an unspecified time with Anonymous revealed the facility had been out of Penner whirlpool disinfectant for about 1 month and the staff had not been able to clean the whirlpool jets. Anonymous revealed the staff had been told in the past to never use any disinfectant in the whirlpool jets except for the Penner disinfectant or it would ruin the jets. When the facility ran out of the Penner disinfectant about 1 month ago, the facility instructed the staff to use a disinfectant from Housekeeping that was supposed to still be able to kill the germs but was not a Penner product. The staff had been cleaning the tub but not the jets so as not to ruin the jets, yet the staff were still providing baths to the residents in the whirlpools but not turning the jets on. Anonymous confirmed when giving the baths the water line was above the jet holes in the tub. Anonymous confirmed residents with catheters and wounds had been receiving baths during the time frame of the jets not being cleansed. Observation on 9/10/19 at 8:43 PM revealed NA-N performed a bath in the whirlpool on Resident 8. When done with the bath, observed NA-N cleanse the whirlpool tub and used A456II disinfectant. NA-N took the whirlpool chair seat apart and cleaned it while inside the tub and scrubbed the tub chair and the tub thoroughly. NA-N did not spray disinfectant into the jets. When done scrubbing, NA-N sprayed everything again then let it sit wet for 10 minutes. Interview with NA-N revealed the whirlpool tubs were cleansed between each resident use and there was one more bath to be given that night. NA-N confirmed the facility had been out of the Penner disinfectant that was supposed to be used to clean the whirlpool and jets and it had been approximately 1-2 weeks that they had been out. Instead the staff had been using the disinfectant A- and NA-N confirmed the staff did not put A- into the jets. NA-N revealed with the Penner disinfectant the staff sprayed it into the jets and let the jets run for 2 minutes, but now they do not disinfect the jets. They continue to bathe in the whirlpool but do not turn on the jets. Interview on 9/10/19 at 8:50 PM with the DON revealed the DON had been aware the facility had been out of the Penner disinfectant at one point but knew the facility had tried re-ordering more and thought the re-order had come in. The DON revealed the DON was never aware the staff were not cleaning the whirlpool jets. The DON revealed during the time when the DON knew the facility was out of the Penner disinfectant, the DON had checked the A disinfectant specs before using it to ensure it was approved to kill the same type of germs and could be used in regular tubs. The DON ceased any further whirlpools to be given in the facility until the facility could investigate, re-educate staff and ensure the whirlpools were cleansed appropriately before any more baths were given. The DON revealed showers would be given instead. Interview on 9/11/19 at 7:55 AM with RN-B revealed the Infection Control reports reviewed the facility had no infections in Sept or Aug of UTI's (urinary tract infection) or wound infections. RN-B provided a report which showed the only infections for the 2 months was an URI (upper respiratory infection). Review of the Product Specification Document for A- Disinfectant Cleaner revealed it was a one-step disinfectant cleaner, fungicide, virucide, mildewstat, and deodorizer to be used and then let set 10 minutes It [MEDICAL CONDITION](human immunodeficiency virus), HBV([MEDICAL CONDITION] virus), and HCV ([MEDICAL CONDITION] virus) and was a hospital use disinfectant bactericidal and had an entire list of bacteria it killed. Review of a list provided by the DON on 09/11/19 at 1:59 PM revealed 47 residents had a tub bath in the whirlpool. The residents were Residents 7, 27, 21, 4, 9, 14, 25, 44, 39, 34, 37, 53, 49, 48, 16, 33, 5, 2, 3, 38, 10, 26, 15, 11, 36, 51, 1, 8, 41, 18, 46, 6, 40, 32, 47, 45, 30, 28, 31, 43, 17, 20, 13, 50, 24, 23, and 35. Review of the facility matrix and by observation of these residents revealed out of the list provided by the DON, the following residents had a urinary catheters: Resident 53. The following residents had open wounds and received a bath in the whirlpool: Resident 5 with a pressure ulcer on the right buttocks measured on 8-19-19 at 0.5 x 0.3 x 0.4 cm (centimeters) and Resident 16 with pressure area on the ear. |
2020-09-01 |