| 5468 |
GOOD SAMARITAN SOCIETY - WOOD RIVER |
285198 |
1401 EAST STREET |
WOOD RIVER |
NE |
68883 |
2017-03-22 |
431 |
K |
1 |
1 |
HUVK11 |
> LICENSURE REFERENCE NUMBER 175 NAC 12-006.12E1 Based on observation, record review and interviews; the facility failed to ensure medications were secured at all times on both units (the SCU: Special Care Unit and general population) with the potential for imminent harm for 18 residents on the SCU. The facility census was 59. Findings are: A Observation on 3-15-17 at 7:39 PM revealed Staff A prepared medications in the med room (medication room) on the SCU (Special Care Unit: a secured unit for residents with dementia) for Resident 50. When Staff A went to administer the medication to the resident, Staff A partially closed the med room door but left it open 2 inches. Staff A went around the corner and administered the medications to the resident. Staff A's back was to the med room door and access to the med room was not within the sight of Staff [NAME] Observation revealed Resident 75 stood at the refrigerator and kitchen counter rummaging through cabinets, drawers, and the refrigerator. The refrigerator was located directly beside the medication room door. - Observation on 3-16-17 at 4:25 PM revealed Nurse [NAME] in the medication room preparing eye drops to administer to Resident 36. Nurse [NAME] exited the med room and left the med room door wide open. The nurse walked away from the med room and the nurse's back was towards the med room the entire time during the administration of the eye drops. When the nurse turned around to go back to the med room, Resident 32 was observed in the resident's wheelchair in the med room with (gender) hands on top of the counter grabbing at items on the counter. Nurse [NAME] hurried back to the med room and intervened and took the resident out of the med room. The resident did not appear to have opened any medications. There were no medications sitting on the counter. The medicaiton room had a countertop with open shelves above the counter to hold stock bottles of multi-dose medications including Tylenol, MOM (Milk of Magnesia: a laxative), and constipation medications. Underneath the cabinet were drawers without locks which held the residents' medications in punch cards. the medications included: Antipsychotic medications: [REDACTED] - Antidepressant medications: [REDACTED] - Antianxiety medications: [REDACTED] - Antihypertensive medication: Midodrine, Vasotec, Spironloactone, Lisinopril, Capoten, Atenolol, - Antiseizure medications: [REDACTED] - Cardiac medications: [REDACTED] - Diuretic medication: Lasix - Anticoagulant (blood thinner) medication: Coumadin Observation on 3-20-17 at 3:21 PM revealed Nurse [NAME] was in the medication room on the SCU. Nurse [NAME] exited the med room and partially closed the door except for approximately 2 inches. Nurse [NAME] asked NA- G (Nurse Aide) to watch the med room as Nurse [NAME] had to leave the SCU to fax the Physician. NA-G was beside the med room working in the refrigerator and verbally agreed. Nurse [NAME] exited the SCU. Resident 52's TABs alarm sounded and NA-G had (gender) back to the med room door while assisting the resident on the other side of the dining room by the office door. NA-H stepped out of a resident room from the far end of the hall by the SCU entry door and asked NA-G to give another resident a root beer which NA-H had forgotten to do. NA-G proceeded to do this. When at 3:23 PM, the TABS alarm sounded again as Resident 52 started crawling out of the chair. NA-G responded and assisted the resident into a different chair. During this time, NA-G's back was toward the med room. While NA-G was assisted Resident 52 and still had (gender) back to the med room, Resident 81 ambulated from the hallway and entered into the dining room directly by the med room door. Resident 63 got up from the activity table and started towards the refrigerator. NA-G finished with the other resident and approached Resident 63. NA-G stood in between the resident and the refrigerator with (gender) back towards the med room and informed the resident it was too early for more chocolate milk. This started an argument between the resident and NA-G. While they were engaged in conversation, Nurse [NAME] returned to the SCU at 3:26 PM and entered into the medication room. Nurse [NAME] exited the med room and closed the door. Nurse [NAME] informed NA-G of the nurse's return. Interview on 3-08-17 at 2:40 PM with Nurse FF revealed Residents 81 and 75 rummage in other residents' rooms, the dining room cupboards, anywhere and whatever they can get their hands onto. Both residents are independently ambulatory. B) Observation on 3-9-17 at 5:18 PM revealed the med cart (medication cart) was located in the 200 hall near the nurses' station was unlocked. The medication drawers on the med cart opened easily and medications in punch cards were observed. No staff were observed in sight of the med cart. Observation at 5:19 PM revealed Nurse C arrived from around the corner and worked on the medication cart. At 5:21 PM, without locking the med cart, Nurse C entered into the medication room out of sight of the med cart. The medication room door was closed shut. Observation on 3-15-17 at 2:35 PM revealed the medication cart was located in the 200 hall near the nurses' station. The medication drawers on the cart opened easily and medications in the punch cards were observed. At 2:36 PM, both of the nurses were observed around the corner in the medication room and the medication cart was not within their view. Observation on 3-15-17 at 5:15 PM revealed the medication cart was located in the 200 hall near the nurses' station and was unlocked. No staff observed in the area. Observation at 5:17 PM revealed Nurse C returned to the med cart from a resident's room. Observation on 3-15-17 at 5:37 PM revealed Nurse C at the med cart located in the 200 hall by the Nurse' Station. Nurse C left the med cart unlocked while Nurse C entered into the medication room to prepare insulin for Resident 22. At 5:40 PM, Nurse C exited the medication room and left the door open without another nurse or Medication Aide in the view of the door. Nurse C entered into Resident 22's room to administer the insulin. The resident was not in the resident's room, so Nurse C went to the Dining Room and brought the resident back the resident's room. Nurse C then left the unit and entered into the SCU (Special Care Unit - a secured unit behind a locked door) to have another nurse check the insulin. During this time, the medication cart and medication room remained unlocked on the 200 hall. No other nurses or medication aides were observed in view of the medication cart or medication room. Observation at 5:46 PM revealed Nurse C returned to the unit to administer the insulin and shut the medication room door but did not lock the medication cart. Observation on 3-15-17 at 8:40 PM revealed the med cart located in the 200 hall by the Nurse's Station was unlocked and the medication drawer opened easily. On top of the med cart was 2 plastic medication cups, 1 with 10cc (cubic centimeters) of a white, milky liquid and the other cup with 10 cc of a light orange liquid in it. Around the corner in the medication room, Nurse C was observed in a cupboard with the nurse's back to the door. The medication cart was not in view when the nurse was inside the medication room. Residents were in the solarium by the nurses' station, but none were wandering. Observation at 8:43 PM revealed Nurse C came out of the medication room to the med cart. Interview on 3-16-17 at 10:52 AM with Nurse D revealed the nurse's understanding of the facility policy was anytime the medication cart or medication room was not within eyesight, it should be locked. The immediate jeopardy was abated to an [NAME] level on 3-20-17 at 6:15 PM when: 1) The facility educated all the nursing staff that the medication room must be locked at all time when the person passing the medications without exception was not inside the medication room. 2) All medication carts were to be locked when not in direct view of the person passing the medications. 3) A sticker strip was placed on the medication counter that stated lock medication room door in the SCU medication room. 4) A sticker strip was placed on the medication carts in the general population that stated lock the medication cart and on the door of the medication room to keep the door closed and locked. 5) All Nurse Aides were educated they were not allowed into the medication room and the staff mail boxes were relocated to the staff break room to alleviate opportunities for staff to be in the medication room unattended. 6) Auditing of medication administration passes and the doors began on 3-20-17 by the DON and the Corporate Nursing and QA Consultants and will continue through the facility QA daily for 1 month, then weekly for 1 month, then monthly for 10 months. Audits will be reviewed by the QA Consultant weekly for 3 months to ensure substantial compliance. |
2020-01-01 |