| 6919 |
GOOD SHEPHERD LUTHERAN HOME |
285148 |
2242 WRIGHT STREET |
BLAIR |
NE |
68008 |
2015-08-27 |
323 |
K |
1 |
0 |
PN1L11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and staff interview, the facility failed to ensure residents were free from a potential injury of a scald from hot liquids. This finding constituted an Immediate Jeopardy situation. This had the potential to affect Residents 61, 63, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79 and 80. The facility census was 77. Observation of the secure care unit on 8/27/15 at 5:30 AM revealed an open kitchenette area located in the dining/lounge area of the unit where residents with a [DIAGNOSES REDACTED]. The area was not visible from the nurse's station. An interview of Registered Nurse 30 (RN 30) was conducted on 8/27/15 at 5:40 AM and a temperature test of the hot liquids was verified by RN 30. A test of the temperature of the liquid dispensed on 8/27/15 at 5:40 AM from the automatic hot drink dispenser revealed the cappuccino and hot chocolate liquid dispensed was 161 degrees Fahrenheit. The hot coffee was tested for a temperature of 163 degrees Fahrenheit. RN 30 was advised of the serious and immediate concerns by the survey team. RN 30 verified the drink dispenser and the coffee maker were located in an area accessible to residents on the dementia unit and the area was unsupervised. RN 30 unplugged the hot beverage dispensers and left the unit. Interview of Licensed Practical Nurse 40 (LPN 40), who was working the secure care unit on 8/27/15 at 6:00 AM, identified the following residents as confused residents who wander on the secure unit: R61, R63, R70, R71, R72 and R73 and was advised of the serious concerns for potential injury to residents by the liquids dispensed from the hot beverage machines in an unsupervised area. Observation of two facility staff Certified Nursing Assistants (CNAs) on 8/27/15 at 6:05 AM revealed they plugged the units back in to an electrical outlet and turned the hot beverage machines on and made coffee. The two CNAs then walked out of the dining area, leaving the two drink dispensers unsupervised and back in operation. The facility failed to provide supervision in the area of the hot beverage dispensers. The facility administrator and the Director of Nursing were notified of the serious concerns by the survey team on 8/27/15 at 9:30 AM. The facility Administrator was notified of the recommendation of Immediate Jeopardy in the area of accident hazards on 8/27/15 at 9:50 AM. The Immediate Jeopardy was removed on 8/27/15 at 11:00 PM and continued at a lower severity level when the facility completed the following corrective actions: 8/27/15 at 10:00 AM, all hot fluid machines were disconnected and moved to the main kitchen away from resident accessibility 8/27/15 at 10:20 AM, six dietary staff were educated. A new procedure was put in place regarding hot liquids. All hot fluids were to be placed in carafes and taken to the dining rooms. The dietary staff would measure the temperature of the liquids and make certain the fluid temperature would not scald a resident if contact was made with skin. Dietary staff would document the temperatures of liquids sent to the resident dining area on a flow sheet in order to ensure temperatures of hot liquids remained at a level below 120 degrees Fahrenheit The Quality Assurance Committee representative would review all documentation related to fluid temperature monitors to ensure safety daily for seven days, weekly for four weeks and monthly for six months. All documentation would be reviewed quarterly through the next annual survey On 08/27/15 at 2:00 PM, 6:00 PM and 10:00 PM, all staff would attend a mandatory meeting and would be educated on the awareness of hot fluids and safety of the residents. Observation of the secure care unit on 8/27/15 at 5:30 AM revealed an open kitchenette area located in the dining/lounge area of the unit where residents with a [DIAGNOSES REDACTED]. The area was not visible from the nurse's station. Staff interview of Certified Nurse Assistant 81 (CNA 81) on 8/27/15 at 6:10 AM revealed the hot beverage dispensers were for the use of residents and visitors. CNA 81 stated residents were able to get a beverage if they wished. Further observation of the hot beverage dispensers was continued to determine if residents used the dispensers without staff supervision. Observation of R63 on 8/27/15 at 7:08 AM revealed the resident walked into the dining area and obtained a cup of coffee with cappuccino mixed. The cup was filled to the top. The resident spilled a portion of the hot beverage on her hand as she attempted to carry the drink to a table. The resident stated ouch, ouch, ouch and wiped her hand with a paper towel. Review of the clinical record for R63 revealed the resident had a [DIAGNOSES REDACTED]. The assessment documented the resident wandered daily. The assessment documented the resident required supervision for eating. Interview of Medication Aide 90 (MA 90) on 8/27/15 at 8:12 AM verified the hot beverage center was available for use by residents on the 200, 300 and 400 units. Observation of the beverage center off the main dining room on 8/27/15 at 8:12 AM revealed a hot beverage dispenser for coffee and hot chocolate. A test of the temperature of the liquids dispensed revealed the coffee was 158 degrees Fahrenheit and the hot chocolate was 160 degrees Fahrenheit. Residents identified by Registered Nurse 100 (RN 100) on the facility units 200, 300 and 400 at risk for injury by the hot liquids dispensed from the beverage center located in the main dining room with a [DIAGNOSES REDACTED]. Observation of the kitchenette area on 8/27/15 at 10:00 AM and the beverage center off the main dining room verified all hot liquid beverage machines had been removed from unsupervised areas accessible to residents who were confused and mobile. On 8/27/15 at 2:00 PM, the facility Administrator provided the first in-service of staff, which was also attended by the state surveyor, who was observing the survey. The education presented to staff included the risk of burn with hot fluids and the process regarding how to reduce the risk of scald. The Administrator explained how the facility was going to ensure the coffee was not served too hot to protect the residents from burns. The dietary staff were to ensure the coffee had cooled to 120 degrees Fahrenheit and were to ask the residents if the coffee temperature was acceptable. The facility planned to complete hot liquid assessments on all residents to assess their risk. The facility planned to complete a care plan for the residents at risk of hot liquid spills. The staff were instructed to use coffee cups with lids. There were 70 staff members at the first in-service on 8/27/15 at 2:00 PM. The Administrator planned to hold additional in-services on 8/27/15 at 6:00 PM and at 10:00 PM. The in-service was mandatory education for all staff. Interview of the facility staff on 8/27/15 between 2:30 and 3:00 PM following the in-service held at 2:00 PM included seven Certified Nurse Assistants (CNA), the Activity Director and five Registered Nurses. All staff evidenced knowledge of the procedure put in place on 8/27/15 to ensure residents' safety in relation to hot liquids. During the staff interviews, facility staff voiced a concern regarding the hot beverage machine on the Secure Care Unit previous to the identification by the surveyor team, but revealed no action had been taken by the facility. This included interviews with two nurses and three CNAs who wished to remain anonymous. |
2018-08-01 |