| 7001 |
NEBRASKA CITY CARE AND REHABILITATION CENTER, LLC |
285109 |
1420 NORTH 10TH STREET |
NEBRASKA CITY |
NE |
68410 |
2014-12-11 |
490 |
H |
0 |
1 |
9RWM11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on record reviews, observations and staff interviews; the facility administration failed to maintain a system to prevent non-compliance with Federal and State regulations related to assuring residents were protected from injury due to hot water temperatures in resident care areas, Maintanance of the resident environment related to the condition of the facility and failed to implement interventions to prevent accidents. The facility census was 50. A. Record review of an unused and undated Maintenance Director Orientation information check list revealed at the section titled: Water Temperature revealed the following: -Notify the Executive Director immediately of any water Temperature above 110 degrees Fahrenheit. -Water must be shut down so that residents can not utilize in the affected area, until the temperature is returned to 110 degrees Fahrenheit. Record review of a Preventative Maintenance (PM) rounds sheet dated 9-15-2014 revealed the following information: -Bathing water temperature on the skilled side of the facility was 117.8 degrees. There was no temperature of the bathing water on the secured unit of the facility. Record review of a PM rounds sheet dated 11-27-2014 revealed the following information: -Bathing water on the skilled side of the facility was 117.8 degrees. There were not any temperature of the bathing water in the secured unit of the facility. Record review of a PM rounds sheet dated 12-02-2014 revealed the following information: -Bathing water on the skilled side of the facility was 123.5 degrees. There were not any temperatures obtained of the bathing water on the secured unit of the facility. -room [ROOM NUMBER], the handwashing sink water temperature was 123.5 degrees. -room [ROOM NUMBER], the handwashing sink water temperature was 123.2 degrees. -room [ROOM NUMBER], the handwashing sink water temperature was 124.5 degrees. -room [ROOM NUMBER], the handwashing sink water temperature was 124.8 degrees. Observation of water temperatures in the residents' handwashing sinks revealed the following: - 12-02-2014 at 12:08 PM, room [ROOM NUMBER],handwashing sink water temperature was 124.9 degrees. -12-02-2014 at 2:03 PM, room [ROOM NUMBER],handwashing sink water temperature was 128.4 degrees. -12-02-2014 at 12:09 PM, room [ROOM NUMBER], handwashing sink water temperature was 124.1 degrees. -12-02-2014 at 2:08 AM, room [ROOM NUMBER], handwashing sink water temperature was 129.2 degrees. -12-02-2014 at 12:13 PM, room [ROOM NUMBER]. handwashing sink water temperature was 127.2 degrees. An interview with the facility Maintenance Director (MD) was conducted on 12-02-2014 at 12:35 PM. During the interview, the MD reported having been employed at the facility about a year. When asked if (gender) had an orientation to the position and what the water temperatures should be for both, handwashing skins and bathing, the MD stated no. When asked what the water temperature should be for bathing and for resident handwashing sinks, the MD stated I'm not sure. A follow up interview was conducted with the MD on 12-02-2014 at 1:18 PM. During the interview, when asked about the bathing water temperatures in the secured unit , the MD stated I don't do that shower. On 12-03-2014 at 8:20 AM an interview was conducted with the facility Administrator. During the interview, the administrator reported the MD had been employed prior to the current Administrator. When asked about the MD orientation, the facility Administrator reported there was not any check list to indicate what the MD had been educated on in the facility. B. Observation the facility during an environmental tour on 12/09/2014 between 8:30 AM - 11:00 AM conducted with the facility Administrator and MD revealed the following areas: -Ventilation system not functioning in resident rooms were not functioning. -Urine odors noted in rooms: 115, 103, 113, 320, 324, and 325. -Caulking peeling or cracked behind the sink in the bathrooms and around toilet bases in resident rooms. -Kick guards of door chipped and or peeling away from the door of residents rooms. -Bolt sticking out of wall where old toilet paper hanger was located in residents rooms. -Rotting boards under heating/cooling unit in room [ROOM NUMBER]. -Behind the main nurses ' station, sink had coving and caulking coming away from the wall and caulking stained. Dark spots located on ceiling above the chart rack and red spots on wall above counter top to the left of the chart rack. -Alzheimer ' s unit kitchenette had sheet rock crumbling off the wall behind the sink and laminate bubbled and peeling off the back splash of counter behind the sink. Wall paper was peeling off the south wall by the window. An interview with Administrator and Maintenance Director on 12/09/2014 at 11:04 AM confirmed these findings during the environmental tour. C. Record review of Resident 41's Comprehensive Care Plan (CCP) reviewed on 9-10-2014 revealed Resident 41 was identified at risk for injury or falls related to weakness, dementia, poor balance and a history of falls. The goal was Resident 41 would not have any fall related injury requiring hospitalization . Intervention identified on the CCP included Foot wear to prevent slipping, Bed and wheelchair alarm. According to the CCP, this intervention was initiated on 6-09-2013 and reviewed on 9-09-2014. Further review of Resident 41's CCP revealed Resident 41 was incontinent with a goal to prevent Urinary Tract Infections [MEDICAL CONDITION] and a goal listed here dated 6-13-2013 was to use a chair alarm. Resident 41's CCP had a hand written entry dated 10-20-2014 that identified Resident 41 had a fall with a resulting laceration to the head that required staples. Record review of a Fax sheet dated 10-20-2014 revealed the facility had informed Resident 41's physician that Resident 41 had been sent to the hospital and received 3 staples. On 12-09-2014 at 11:20 AM an interview was conducted with the Director of Nursing (DON). During the interview, Resident 41's CCP and the VOI dated 10-20-2014 was reviewed with the DON. The DON confirmed that according to Resident 41's CCP, Resident 41 should have had an alarm on prior to the fall on 10-20-2014. According to the DON, the alarm was removed as Resident 41 had not recently fallen. When asked if an evaluation to remove the alarm had been completed, the DON stated no. |
2018-07-01 |