| 10199 |
ELLEN SAGAR NURSING HOME |
425012 |
1817 JONESVILLE HIGHWAY |
UNION |
SC |
29379 |
2010-09-15 |
323 |
D |
|
|
A4CW11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on observations, record reviews, and interviews, the facility failed to ensure that the resident environment remained free of accident hazards as was possible and that each resident received assistance devices to prevent accidents. Random observations were made of unattended paint thinner accessible to cognitively impaired, mobile residents and of bottles of Hydrogen Peroxide (H2O2) stored unsecured in Resident #3's bathroom. The facility also failed to provide interventions as required to minimize injury for one (1 )of 6 sampled residents reviewed for falls. Resident # 6 who was assessed at high risk for falls did not have a low bed and mats provided as per the plan of care. The findings included: On 9/14/10 at 10:50 AM a random observation was made by two surveyors on Unit 1 Maple Lane in the patient shower area of an unattended 1 gallon container of Paint Thinner on the window sill and 2 paint cans without covers containing paint thinner, soaked brushes, and rags soaked in paint thinner. There was a strong odor of the chemical in the shower area and in the Maple Lane Hall. The label on the Paint Thinner read, "DANGER: COMBUSTIBLE LIQUID, FLAMMABLE--HARMFUL OR FATAL IF SWALLOWED". The Material Safety Data Sheet (MSDS) provided by the Administrator on 9/14/10 read : "RISK STATEMENTS-Irritating to eyes, respiratory system, and skin. Harmful by inhalation, may cause lung damage if swallowed. Harmful in contact with skin. Vapors may cause drowsiness and dizziness". SAFETY STATEMENTS on the MSDS read: "Avoid contact with skin and eyes, Keep container tightly closed. Do not breathe gas, fumes, vapor, or spray, Keep away from sources of ignition. Take precautionary measures against static discharges." HANDLING AND STORAGE SECTIONS of the MSDS stated, "STORAGE : Vapors may ignite explosively and spread long distances. Prevent vapor build up. Keep cool and keep in the dark. Do not store above 49 C/120 F(Fahrenheit). Keep container lightly closed and upright when not in use to prevent leakage." "HANDLING: Use only with adequate ventilation. Avoid breathing of vapor of spray mist. Avoid contact with skin and eyes. Wear OSHA standard goggle or face shield. Wear gloves, apron, and footwear impervious to this material. Wash clothing before reuse. Avoid free fall of liquid. Empty container very hazardous!" Residents in nearby rooms #17 and #15 were using oxygen at the time of the random observation and a fan was blowing in the hall by the shower room with the observed Paint Thinner. In an interview on 9/14/10 at 11:00 AM with the Administrator and Environmental Services Manager they recognized the paint thinner as a hazardous chemical and removed if from the premises promptly. The Administrator stated they had contracted painters to repaint the facility halls and the Paint Thinner was left by the painters who were currently using the product. He stated that he had informed them prior to the start of the painting of the halls to remove unattended hazardous chemicals while painting the facility. He did not have a formal, written contract with the paint company, or evidence of this instruction. Following completion of tracheal suctioning and care on 9-14-10, Registered Nurse (RN) #1 removed the two-tiered wired basket cart containing all tracheostomy suctioning and care supplies from Resident #3's room. She stated that it was routinely stored in the resident's bathroom. The cart contained two 16 ounce bottles of Hydrogen Peroxide which were labeled, "Harmful if swallowed. Keep out of the reach of children." On 9-15-10 at 10:45 AM, Licensed Practical Nurse (LPN) #4, while preparing to perform tracheostomy care for Resident #3, stated that she had obtained the cart containing the H2O2 and other supplies from the unlocked resident bathroom. The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Record review on 9-14-10 at 1:55 PM revealed that resident was assessed at high risk for falls on the most recent Fall Risk Assessment completed on 7-20-10. The 7-22-10 Care Plan noted that the resident was to have a "Low bed with mats". The 7-22-10 Quarterly Minimum Data Set Assessment noted the resident with both short- and long-term memory problems and varying mental function. On 9-13-10 at 9:35 PM, the resident was observed in a low bed, but without mats in place. The resident was observed in a regular height bed without mats on 9-14-10 at 9 AM, 10:15 AM, 12:05 PM, 1:30 PM, and 3:50 PM. During an interview on 9-14-10 at 4 PM, Certified Nursing Assistant (CNA) #1 stated that she did not know how long the resident had not had the low bed/mats. She was aware that the resident was supposed to have them "because it's on the Basic Care Sheet (CNA Care Plan)." During an interview on 9-14-10 at 3:50 PM, RN #2 checked the Documentation Record and verified that it indicated that the resident was to have a low bed with mats. The form noted "FYI" next to the intervention which RN #2 stated meant that the nurse was to check to assure the item was in place. She went to the resident's room and verified that the resident was in a regular height bed without mats. The nurse was unable to lower the bed and was unable to locate mats in the room for the resident. |
2014-03-01 |