Alameda County Medical Center D/P SNF

In the surveyor’s words

From the most serious findings on record at Alameda County Medical Center D/P SNF, in the surveyor’s own words.

• Actual harm, isolatedF600Oct 5, 2021

  Based on observation, interview, and record review, the facility failed to ensure one (Resident 1) of three residents' call lights were within reach for resident use, preventing Resident 1 from being able to notify staff for 30 to 60 minutes, that he needed suctioning to remove excess saliva. The failure to place Resident 1's air blow call light (a hands-free method used to activate a call light by blowing through a tube) within his reach resulted in physical and emotional distress and potentially contributed to a three-day hospitalization for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: A review of Resident 1's Face Sheet indicated Resident 1 was admitted to the facility in July 2020, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF812Aug 22, 2024

  Based on observation, interview and record review, the facility failed to ensure 106 of 106 residents had food prepared and stored in a safe and sanitary manner when: 1. frozen raw tilapia and frozen raw shrimp was stored above ready to eat chicken enchiladas and bean and cheese pupusas. 2. a dispensing scoop was stored in panko breadcrumbs. 3. staff did not perform hand hygiene when their hands were contaminated by picking up a clipboard which fell on the floor. These failures placed the facility's 106 residents who received food from the kitchen at risk of foodborne illness. Findings: 1. […]

• No harm, potential for more than minimal, patternF759Jul 28, 2023

  Based on observation, interview and document review, the facility failed to ensure the facility had a medication error rate of less than 5 percent when nursing staff failed to follow physician orders for administration of medication for two of eight sampled residents (Resident 89 and Resident 231) during medication pass: Resident 89 did not receive an ordered blood test before meals and Resident 231 did not receive the correct dosage of medication during medication pass. The failure to follow medication administration instructions during two of 28 opportunities of medication administration resulted in an error rate of 7.1 percent. Findings: 1. […]

• No harm, potential for more than minimal, patternF880Jul 28, 2023

  Based on observations, interviews, and document reviews, the facility failed to ensure staff followed policies and procedures designed to prevent infection and spread of infection when: 1. For two of five unsampled residents (Resident 105, Resident 229), a Licensed Vocational Nurse (LVN 1) failed to clean the blood glucometer (instrument to check the level of sugar in the blood: blood glucose) in between resident use. 2. For one of four sampled residents (Resident 83) with wound care issues, LVN 1 stored clean wound care supplies in a resident room and failed to discard a bottle of normal saline (NS, salt-water solution) used for wound irrigation opened inside the resident room. These failures had the potential to cause infection or spread infection for Residents 105, 229, and 83. […]

• No harm, potential for more than minimal, isolatedF755Aug 22, 2024

  Based on observation, interview, and record review the facility failed to ensure safe practices on storage and handling of the hazardous medications (or HD, Drugs that pose short- or long-term harm upon exposure to human via skin or inhalation) in three out of six medication carts with resident census of 106 based on CDC's (Centers for Disease Control and Prevention, a federal agency leading the science-based, data-driven, service organization that protects the public's health) National Institute for Occupational Safety and Health (NIOSH a federal agency that is part of the CDC; NIOSH conducts research and makes recommendations for the prevention of work-related hazards, injury and illness) guidelines. […]