**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility staff failed to provide an environment free of accident hazards related to properly and securely storing medications and failed to obtain consent and assess risk of entrapment from bedrails for 7 sampled residents (#1, #2, #4, #6, #7, #10, and #14) out of a total of 17 sampled residents.
Findings include:
1. During the medication pass observation on 9/27/17 at 9:05 A.M. on the facility secure unit – station 2, the following was observed:
Nurse #1 brought the medication cart into the day room and placed it facing inward against the wall to the left of the doorway . The day room had multiple tables, stationary chairs, wheelchairs and residents in the room. Residents and facility staff were observed ambulating independently in and out of the day room passing by the medication cart. Nurse #1 proceeded to prepare multiple medications for administration to Non-sampled (NS) Resident #2 that included oral medications and a Combivent (brochodilator) inhaler. After preparing the medications for NS #2, the Nurse locked the medication cart and left the Combivent inhaler on top of the cart. She proceeded to bring and administer the oral medication to NS #2 who was seated on the other side of the open doorway, approximately 15 feet away from the medication cart. The medication cart was out of view of Nurse #2 as she was facing the resident.
Nurse #2 returned to the medication cart and proceeded to prepare medications for another resident NS#3. She locked the medication cart, leaving the Combivent inhaler from NS #2 unsecured and accessible on top of the medication cart. She then walked away from the medication cart and once again the medication cart was out of her view, as she administered the prepared medications to NS #3.
During an interview with Nurse #1 on 9/27/17 at 9:20 A.M., she said that the inhaler should have been locked in the medication cart and not left on top.
2. During the medication pass observation on station 1 on 9/27/17 at 9:45 A.M., the following observation was made:
Nurse #2 was preparing multiple medications for administration to sampled Resident #10, including an intravenous (IV) medication Vancomycin (antibiotic). The nurse went into the medication room and obtained the necessary supplies to administer the IV medication. These supplies included tubing and a Normal Saline (NS) flush required to instill in the IV access line to ensure patency prior to administering the medication. However, there were no NS pre-fill syringes in the medication room for Resident #10. The nurse said she hoped that there was a NS flush available in the Resident’s room. The surveyor asked if the pre-fill NS syringes were kept in the resident’s room and the nurse said she did not store them in the resident’s room. Upon entering Resident #10’s room, Nurse #2 opened the top bureau drawer and obtained a 0.9% NS 10 cc pre-fill syringe from a pharmacy labeled plastic bag that contained 3 pre-filled NS flush syringes. During an interview with the Assistant Director of Nurses (ADON) on 9/27/17 at 5:00 P.M., she said that all IV supplies are kept locked in the medication room including IV flushes. She further said that pre-filled IV flush syringes are not to be left in a resident’s room.
3. For Resident #6 facility staff failed to obtain consent and assess risk of entrapment from bedrails, as required. Resident #6 was admitted to the facility 3/2017 with multiple [DIAGNOSES REDACTED]. Review of the current Physician orders [REDACTED]. Review of the clinical record did not indicate that informed consent was obtained by the resident or responsible party for the use of siderails, nor was there any safety assessment completed for the risk of entrapment, as required. Observation of the resident in bed on 9/27/17 at 8:45 A.M. and again on 9/29/17 at 9:00 A.M., the head of the bed was elevated approximately 75 degrees. Upper bilateral 1/2 siderails/grabbars and bottom right 1/2 siderail were in the up position. During an interview with Unit Manager (UM) #1 on 9/29/17 at 9:05 A.M., he said that he did not know why there were three 1/2 siderails up and that it was a mistake.
4. For Resident #7 facility staff failed to obtain consent and assess risk of entrapment from bedrails, as required. Resident #7 was admitted to the facility 6/2016 with multiple [DIAGNOSES REDACTED]. Review of the current Physician orders [REDACTED]. Review of the clinical record did not indicate that informed consent was obtained by the resident or responsible party for the use of siderails, nor was there any safety assessment completed for the risk of entrapment, as required.
5. For Resident #10 facility staff failed to obtain consent and assess risk of entrapment from bedrails as required. Resident #10 was admitted to the facility 9/2017 with multiple [DIAGNOSES REDACTED]. Review of the current Physician orders [REDACTED]. Review of the clinical record did not indicate that informed consent was obtained by the resident or responsible party for the use of siderails, nor was there any safety assessment completed for the risk of entrapment, as required. During an interview with UM #1 on 9/29/17 at 9:05 A.M., he said that there is no consent for use of siderails and a safety risk assessment for entrapment is not completed prior to the use of siderails.
6. For Resident #1, the facility staff failed to obtain informed consent for the use/application of side rails. The facility failed to ensure that the safety of the side rails was assessed for entrapment. Resident #1 was admitted to the facility in 3/2017 with [DIAGNOSES REDACTED]. Review of the 8/17/16 Ancillary Physician order [REDACTED]. During an observation on 9/27/17 at 12:30 P.M., the resident’s bed had 2 side rails in the up position. Review of the clinical record did not indicate that informed consent was obtained by the resident and/or responsible party for the use of side rails, nor was there any safety risk assessment completed, as required.
7. For Resident #2, the facility staff failed to obtain informed consent for the use/application of side rails. The facility failed to ensure that the safety of the side rails was assessed for entrapment. Resident #2 was admitted to the facility in 9/2016 with [DIAGNOSES REDACTED]. Review of the 8/17/16 Ancillary Physician order [REDACTED]. During an observation on 9/26/17 at 8:30 A.M., the resident’s bed had 2 side rails in the up position. Review of the clinical record did not indicate that informed consent was obtained by the resident and/or responsible party for the use of side rails, nor was there any safety risk assessment completed, as required.
8. For Resident #4, the facility staff failed to obtain informed consent for the use/application of side rails. The facility failed to ensure that the safety of the side rails was assessed for entrapment. Resident #4 was admitted to the facility in 10/2013 with [DIAGNOSES REDACTED]. Review of the 10/22/13 Ancillary Physician order [REDACTED]. During an observation on 9/26/17 at 8:50 A.M., the resident’s bed had 2 side rails in the up position. Review of the clinical record did not indicate that informed consent was obtained by the resident and/or responsible party for the use of side rails, nor was there any safety risk assessment completed, as required.
9. For Resident #14, the facility staff failed to obtain informed consent for the use/application of side rails. The facility failed to ensure that the safety of the side rails was assessed for entrapment. Resident #14 was admitted to the facility in 1/2016 with [DIAGNOSES REDACTED]. Review of the 1/27/16 Ancillary Physician order [REDACTED]. During an observation on 9/26/17 at 8:55 A.M., the resident’s bed had 2 side rails in the up position. Review of the clinical record did not indicate that informed consent was obtained by the resident and/or responsible party for the use of side rails, nor was there any safety risk assessment completed, as required. During an interview on 9/29/17 at 9:00 A.M., Unit Manager (UM) #2 said the facility does not obtain informed consents from the resident and/or responsible party for the use of side rails and does not complete a risk safety assessment. During an interview on 9/29/17 at 11:30 A.M., the Administrator said the facility staff has not been obtaining informed consents for the use of side rails and complete a safety risk assessment for entrapment and they should have.