cms_SD: 96
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 96 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2018-03-01 | 880 | E | 0 | 1 | 2S8V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the provider failed to ensure: *The Hoyer lift on the 200 hall had cleanable surfaces. *One of one randomly observed resident (10) had clean and unworn hell protector boots. *A bedpan and graduate pitcher in room [ROOM NUMBER] had been stored in a sanitary manner. *A sanitary environment was maintained for: -The storage of resident use equipment in one of one bathroom located on the Transitional Care Unit (TCU). -One of two sampled resident's (320) oxygen tubing when not in use. -The placement of a urinal after it was used for one of one sampled resident (321). -The placement of resident personal care products in two of five randomly observed resident's rooms (110 and 113). -The storage of juice containers in one of one kitchenette on the TCU for one of one juice machine. -The filters in five of five hairdryers located in the main sitting/visiting area on the 300 wing. -One storage room on the 400 wing. Findings include: 1. Observation on 2/27/18 at 11:27 a.m. of the 200 hall Hoyer lift revealed it had a blue fabric and foam covering over the bar where the slings hooked. That covering was opened approximately six inches and had exposed yellow foam poking out. That foam would be uncleanable. 2. Observation on 2/27/28 at 11:35 a.m. of resident 10 revealed she had on heel protector boots. Those boots had Velcro closures. The fabric around the Velcro and on the top and sides of those boots was torn and worn. It was an uncleanable surface. 3. Observation on 3/1/18 at 8:15 a.m. of the bathroom in resident room [ROOM NUMBER] revealed a wash basin and bedpan sitting on the floor directly below the sink. There had been no covering or barriers in place to protect those items from contamination from the floor. 4. Interview on 3/1/18 at 8:45 a.m. with the director of nurses (DON) revealed she agreed: *The padding on the Hoyer lift bar needed replacing and had been an uncleanable surface. *Resident 10's heel protector boots needed to be replaced and had been uncleanable. *The wash basin and bedpan should not have been on the floor in resident room [ROOM NUMBER]'s bathroom. Review of the provider's last revised (MONTH) (YEAR) Laundry and Linen policy revealed all washable residents' personal equipment would be laundered if soiled. 5. Observation on 2/27/18 at 11:05 a.m. of a bathroom on the TCU located across from the therapy department revealed: *The bathroom with a toilet, sink, and bathtub had been identified as a shared female/male bathroom by a sign attached to the door. *There had been several types of resident use equipment stored in that bathroom such as: -A wheelchair (w/c) weighing scale. -A large wooden mirror that had wheels on the bottom of it for movability. -Two small plastic bins sitting directly on the floor next to the bathtub. -A shower chair. -A w/c. -Several walkers hanging on hooks. -A red therapy bolster sitting directly on the floor. -Two large bouncy balls located on a shelf above the walkers. Interview on 2/27/18 at 11:10 a.m. with speech therapist (H) regarding the above observation revealed she: *Had been unsure: -What the bathroom was used for. -If the bathroom was used for storage or not. *Stated But I know the visitors use that for a bathroom. Observation and interview on 2/27/18 at 11:44 a.m. with the administrator regarding the TCU bathroom revealed she: *Had been unaware that: -Visitors had been using that bathroom. -The staff had been storing resident use equipment in that bathroom. *Stated: -Visitors should not be using that bathroom. -Staff shouldn't be storing equipment in there. -That bathroom is to be used by therapy with the residents for training purposes only. *Agreed with visitors using the bathroom they could not guarantee the equipment that was stored in there was kept clean. Observation and interview on 2/27/18 at 2:00 p.m. with physical therapist (PT) G regarding the TCU bathroom revealed he: *Had been aware that visitors used that bathroom. *Had been aware resident equipment was stored in that bathroom. *Stated: -The staff use it as well. Its the only bathroom close to this area. -We mostly use the bathtub when working with residents who are going home and have a bathtub. *He agreed: -The equipment was not stored in a clean environment. -That process had created the potential for bacteria to spread from one person to another. 6. Random observations on 2/27/18 from 8:00 a.m. through 3:13 p.m. of resident 320's oxygen tubing revealed: *The resident had been observed using: -His oxygen continuously throughout the day. -An oxygen concentrator when he was in his room. -A portable oxygen tank when not in his room. *At 8:46 a.m. the: -Resident had been in his room and was using the oxygen concentrator. -Portable oxygen tank had been hanging from his walker. -The oxygen tubing attached to that portable tank was on the floor and underneath of his bed. *At 12:51 p.m. revealed the same observation as above. *At 3:08 p.m. the: -Resident had been in the therapy room and was using his portable oxygen tank. -Oxygen tubing attached to the concentrator in his room was lying directly on the floor. Observation and interview on 2/28/18 at 8:35 a.m. with certified nursing assistant (CNA) (D) regarding resident 320's oxygen tubing revealed: *She had not been aware the resident was leaving his oxygen tubing on the floor when not in use. *She stated They usually have a bag attached to the walker and concentrator to put them in. -The concentrator had a bag attached to it, but the walker did not. *The resident had been in the room, and he: -Was not aware that storing the oxygen tubing on the floor when not in use was unsanitary. -Had never been educated by the staff of a different process. *She agreed the process above: -Was not completed in a sanitary manner. -Created the potential for the spread of bacteria to the resident. 7. Random observations on 2/27/18 from 7:55 a.m. through 4:27 p.m. of resident 321 revealed: *He had: -Been admitted from the hospital after having a stroke. --That stroke had caused him to have [MEDICAL CONDITION] on the right side of his body. -Required staff assistance with all activities of daily living (ADL). -Remained continent of urine with the use of a urinal. -Been able to use that urinal independently. -Stored the urinal on his bedside table by his water glass, Kleenex, and other various personal items. -Required the staff to empty the urinal for him after he had used it. *During the above time frame the resident had used the urinal twice. -Both of those times he had: --Filled the urinal a quarter full of urine and placed it on the bedside table for the staff to empty. --Not called the staff to empty the urinal after he used it. *At 4:27 p.m.: -Licensed practical nurse (LPN) C had administered medication to the resident in his room. -He had recently used the urinal, and it was a quarter full of urine. -He had placed the urinal on his bedside table by his water glass and Kleenex. -LPN C administered him the medication and left the room without emptying his urinal. Interview on 2/28/18 at 8:32 a.m. with CNA D regarding resident 321's urinal revealed: *She had been aware the resident placed his urinal on the bedside table. *She confirmed the resident: -Was dependent upon the staff to empty his urinal. -Would not call the staff to empty it after he had used it. -Was alert, oriented, and capable of being educated on a better process for placing/storing his urinal. *The staff had not worked with the resident to see where he could have placed the urinal and still have access to it without difficulty. *She agreed the placement of his urinal was not considered a sanitary process. 8. Random observations on 2/27/18 from 10:36 a.m. through 10:46 a.m. of resident rooms [ROOM NUMBERS] revealed: *Both rooms had large plastic containers sitting on top of the counters by the sinks. *Those containers had various personal healthcare products inside of them such as: -Open bars of soap. -Combs and brushes with hair inside of them. -Packages of wet wipes. -A plastic bag containing used roll of tape inside of it. -Tubes of toothpaste. -Toothbrushes with their bristles unprotected and resting right next to the above items. Observation and interview on 2/28/18 at 8:40 a.m. with CNA D regarding the plastic containers in residents' rooms [ROOM NUMBERS] revealed she: *Confirmed there were personal care products mixed together inside of those plastic containers. *Agreed: -The personal care products should not have been stored together like that. -Mixing those personal care products together had not been a sanitary process. *Stated The toothbrushes should not be stored in there with all of this stuff. 9. Observation on 2/27/18 at 12:15 p.m. of the kitchenette area in the TCU revealed: *There was a juice machine sitting on top of the counter. *Above and below the juice machine was cabinetry with several drawers and doors. *The juice containers that were connected to the juice machine for dispensing were located on a shelf inside of the cabinet below the machine. *The shelf the juice containers were stored on was covered and dirty with thick/gray colored lint particles. Interview on 2/27/18 at the time of the above observation with CNA D revealed: *The staff who worked in the TCU were responsible for the cleaning of the kitchenette area. *There was no specific cleaning schedule for them to follow. *The juice machine had been purchased less than a week ago. *The storing of the containers in the cabinet below was a new process for them. *She agreed the: -Shelf was dirty, and it would have taken longer than a week for that amount of lint build-up. -Placement of those juice containers had not been done in a sanitary manner. -Kitchenette area was to have been as clean as possible to ensure the delivery of food/drinks was done in a safe and sanitary manner. 10. Observation on 2/28/18 at 7:55 a.m. in the sitting area of the 300 wing revealed: *There had been several recliners/chairs located in that area. *Mixed in between those recliners/chairs were five hairdryers. *All five of those hairdryers had lint filters attached to the back of them. *Those filters had: -Been full of a grayish/white colored particle. -Created a small dust ball in the air when pulled out of the hairdryers. 11. Interview on 3/8/18 at 9:41 a.m. with the director of nursing and administrator revealed: *They had not been aware of all the concerns and break in sanitary processes identified above. *They were not sure: -If the hairdryers belonged to the beautician or were owned by the facility. -Who should have been responsible to ensure the filters on the hairdryers had been kept clean. *They agreed the processes above were unsanitary and created the potential for bacteria to have spread to the residents. Review of the provider's (MONTH) 2013 Care and Storage of Resident Personal Care Items policy revealed: *Policy: To assist in the prevention of the spread of infection by assuming resident personal care items are kept clean and stored in the resident's personal area. *Procedures: -Personal care items will be stored in a non-communal area. E.[NAME] such as a toothbrush in a holder. -Items will be placed in a drawer of resident's bedside table in a basin, or in a plastic bag away from other personal care items. -If a personal care item is found to be left out in the resident's bathroom or on top of a nightstand or other area where the sanitation is questionable, it will be discarded and replaced with a new one, or if cleanable, will be disinfected prior to return to storage area. On 2/28/18 at 2:00 p.m. a list of policies and procedures were given to the administrative department and had been requested: *Use of a urinal. *Storage of resident use equipment. *TCU kitchenette cleaning of cabinets/area. *Oxygen tubing placement when attached to concentrators/portable oxygen canisters and not in use. *Those above policies were not provided to the surveyor prior to exit of the facility. Observation on 2/27/18 at 8:30 a.m. of the storage room located on the 400 wing revealed: *The room had been used for mechanical lift storage, five oxygen concentrators, four lift batteries were located on a shelf, one electric scooter with a liquid oxygen cylinder attached, a shower bench, a commode, and other miscellaneous items. *Each wall had chipped paint with the highest concentration being along the bottom of each wall. *There had been scuff marks on all lower walls. *A crack in the exterior wall had been visible under the lower left corner of the window. *There was a door inside this storage room that stated housekeeping supplies. -The door had four areas along the edge which had the top layer of wood missing. --These areas were approximately a quarter in diameter each. -The lower area of the door had two holes. --Each of these holes were approximately the size of a quarter. Interview on 2/28/18 at 9:41 a.m. with the director of nursing revealed: *The storage room walls and door to housekeeping supply area were in need repair. *She agreed they would be considered unable to be cleaned. *She stated it would be maintenance's responsibility to complete these repairs. Observation and interview on 3/01/18 at 3:05 p.m. with the maintenance director revealed: *The storage room down the 400 wing was in need of a new door for the housekeeping supply area. *The walls were in need of repair and paint. *He stated they repair and/or paint four to five rooms per year and prioritize resident rooms before other areas. *He does not want other rooms to be neglected but always tries to do resident rooms first. *This room is on his list for this year. -There is no actual list. It is just on his mind to get done. *He does not have any type of policy regarding when to repair or paint rooms. -He does have a preventative maintenance program for equipment but not for something like this. Observation and interview on 3/01/18 at 3:20 p.m. with the administrator and the medical consultant revealed: *A walk through inspection of the storage room located on the 400 wing had chipped paint on every wall. -The housekeeping storage door located inside the storage room had gouges in the wood. -The room was in need of paint and repair. *Both agreed it would be considered unable to be cleaned. | 2020-09-01 |