Every finding on record at Lake Cumberland Regional Hospital Scu

Based on observation, interview and record review, and review of the facility's policies, it was determined the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections. Observations on 10/18/2023, revealed a phlebotomist did not use Neutropenic Isolation Precautions for one (1) of eleven (11) sampled residents (Resident #263). Additionally, after CPT #1 finished giving care to Resident #263, the State Survey Agency (SSA) Surveyor observed CPT #1 remove her gloves. However, CPT #1 did not sanitize her hands. The findings include: Review of the facility's policy, Transmission-Based Precautions, 900-IC-07, effective 01/18/2023, revealed preventing transmission of infectious agents was a priority in the facility's organization. Personal Protective Equipment (PPE) was worn based on preventing transmission of infectious agents. Isolation signage must be posted with specific instructions on the appropriate PPE that should be worn upon entering the resident's room. Signage should include instructions to staff, patients, and visitors on necessary PPE. PPE would be worn when the anticipated patient interaction indicated that contact with blood or body fluids may occur. Before leaving the resident's room, PPE was to be removed and discarded in the appropriate container. Gloves were to be worn when it could be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, or potentially contaminated intact skin could occur. Gloves were to be removed after contact with a resident and/or the surrounding environment (including medical equipment) using proper technique to prevent hand contamination. Gowns were to be worn that were appropriate to the task that would be performed, to protect skin and prevent soiling or contamination of clothing during procedures and resident-care activities when contact with blood, body fluids, secretions, or excretions. Gowns were to be removed and hand hygiene performed before leaving the resident's environment. Further review of the Transmission-Based Precautions, 900-IC-07 policy section Neutropenic Isolation Precautions, revealed immunocompromised residents varied in their susceptibility to healthcare-associated infections, depending on the severity and duration of immunosuppression. They were at increased risk for bacterial, fungal, parasitic, and viral infections from both endogenous and exogenous sources. Protective Isolation (Neutropenic Precautions) were to be used for those residents on immunosuppressive therapy for a disease process (e.g., radiation, cytotoxic chemotherapy, white blood cell count low). Continued review revealed gloves were to be worn when entering the resident's room and changed after contact with blood or body fluids. Gloves were to be removed before leaving the resident's room and hand hygiene was to be performed immediately. Gowns were to be worn when entering the resident's room to avoid contamination of the resident and their environment. Review of the facility's Admission Demographic Facesheet, revealed the facility readmitted Resident #263 on 10/13/2023. Review of the History and Physical, dated 10/13/2023, revealed Resident #263 had a recent diagnosis of myelodysplastic syndrome (bone cancer). Resident #263 developed neutropenia, (a disease of not enough white blood cells, which are important for fighting bacterial infections) and was discharged back to a skilled nursing and rehab facility on neutropenic prophylaxis and chemotherapy. Review of the Infection Interdisciplinary Care Plan, dated 10/16/2023, and the List Patient Notes, revealed RN #2 documented Resident #263 was in Nutropenic Isolation (steps to prevent infections). Review of the Order History Data, revealed Resident #263 had an order, dated 10/16/2023, for Neutropenic Precautions for Resident #263. During an interview, on 10/18/2023 at 9:00 AM, RN #2 stated Resident #263 was in Neutropenic Precautions, and the lab tech (CPT #1) was in Resident #263's the room waiting on RN #2 to draw blood from the resident's Peripherally Inserted Central Catheter (PICC) line. Observation, on 10/18/2023 at 9:00 AM, revealed therapy staff in Resident #263's room donned (wearing) a gown, gloves, and mask, which was the proper PPE for Neutropenic Precautions according to facility policy. However, there was no signage on the door indicating Resident #263 was in Neutropenic Precautions. CPT #1 was also in Resident #263's room, and was not wearing a gown. After CPT #1 finished providing care to Resident #263, the State Survey Agency (SSA) Surveyor observed CPT #1 remove her gloves, exit Resident #263's room, label the tubes she had just filled with Resident #263's blood, and walk towards the unit's exit. However, further observation revealed CPT #1 did not sanitize her hands. During an interview, on 10/18/2023 at 9:03 AM, CPT #1 stated she did not see a precautions sign on Resident #263's door. During an interview, on 10/19/2023 at 10:45 AM, the Infection Preventionist (IP) stated she performed isolation rounds daily making observations at the facility to ensure correct signage was posted and the needed PPE was available to staff. She stated she tried to perform the rounds in the morning. The IP stated she made rounds at the facility on 10/19/2023 around 10:00 AM. She stated during her rounds she ensured the resident's nurse had put the resident in the proper precautions. The IP stated in order to protect residents from infection, she expected staff to use hand hygiene before going into a resident's room and after removing their PPE. She stated that anyone going in a Neutropenic Precautions room should put on the proper PPE. The IP stated any resident in Neutropenic Precautions should have a sign on the door that explained exactly what to do. Continued interview on 10/19/2023 at 10:45 AM, the IP stated if staff cared for a resident under neutropenic precautions without wearing the proper PPE, her concern would be that the staff member(s) could expose the susceptible resident to a virus or bacteria. She stated the bedside nurse was responsible for ensuring proper isolation signage was on the resident's door and that would include Neutropenic Precautions. The IP said it was the bedside nurse's responsibility to ensure staff caring for the resident under Neutropenic precautions always wore PPE appropriate for that form of isolation.

Based on observation, interview, and facility policy review, it was determined the facility failed to maintain an effective infection control program to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for two (2) of two (2) residents on transmission-based precautions out of eight (8) sampled residents (Residents #58 and #59) On 09/11/19, Licensed Practical Nurse (LPN) #1 entered the room of Resident #59 who was on contact precautions. LPN #1 was observed to use her stethoscope to obtain the resident's blood pressure. After obtaining Resident #59's blood pressure, LPN #1 was observed to place the stethoscope around her neck without sanitizing/disinfecting the stethoscope. Continued observation revealed State Registered Nursing Assistant (SRNA) #1 was observed to enter Resident #59's room to deliver a meal tray. However, SRNA #1 was not observed to don Personal Protective Equipment (PPE) per the facility's policy and procedure. In addition, LPN #1 was observed to obtain a blood glucose reading for Resident #58. After obtaining the blood sample, LPN #1 placed the soiled glucose meter on her Computer on Wheels (COW) and was not observed to clean the COW. The findings include: Review of the facility's policy and procedure titled, Transmission Based Precautions, last revised 11/11/18, revealed transmission-based precautions were designed for patients with known or suspected infections with highly transmissible or epidemiologically important pathogens for which additional precautions are needed to prevent transmission by either direct or indirect contact. In addition, the policy stated contact precautions were a routine strategy of the Centers for Disease Control and Prevention (CDC). Continued review revealed staff were to wear appropriate PPE to prevent transmission of infectious agents. The policy stated staff were to wear gloves when entering a resident's room. Gloves were to be worn when touching the patient's intact skin or surfaces and articles in close proximity to the patient. In addition, the policy stated staff were to wear a gown whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. The policy further stated that staff should dedicate the use of non-critical patient care equipment to a single patient; however, if use of common equipment was unavoidable, the equipment should be adequately cleaned and disinfected before use on another patient. 1. Record review revealed Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued record review revealed Resident #59 was placed on contact precautions due to the stool culture that was positive for VRE. 1. a. Observation on 09/11/19 at 12:49 PM revealed LPN #1 entered Resident #59's room to obtain the resident's blood pressure. Continued observation revealed LPN #1 used her own stethoscope to obtain the resident's blood pressure. Immediately after obtaining the blood pressure, LPN #1 placed the stethoscope around her neck. However, LPN #1 was not observed to sanitize or disinfect the stethoscope before she placed it around her neck. Interview with LPN #1 on 09/11/19 at 5:29 PM revealed she had been trained by the facility regarding contact precautions and infection control. LPN #1 stated she had been trained that if a resident was on contact precautions they should use disposable equipment. LPN #1 stated disposable stethoscopes were supposed to be used for residents in contact precautions; however, LPN #1 stated she was not able to hear very well when she used them. LPN #1 stated she should have cleaned and disinfected the stethoscope after she used it to take Resident #59's blood pressure and before she placed it around her neck. LPN #1 stated this was important to prevent the spread of infection. 1. b. Continued observation of Resident #59 on 09/11/19 at 11:40 AM revealed SRNA #1 entered Resident #59's room with his/her noon meal tray. Further observation revealed SRNA #1 was not observed to don a disposable gown or put on gloves when she entered the resident's room per the facility's policy and procedure. Interview with SRNA #1 on 09/11/19 at 5:17 PM revealed she had been trained to don a gown and gloves anytime she entered a resident's room with contact precautions. SRNA #1 stated she thought she had put on a gown but stated she knew she had not put on gloves. Continued interview revealed SRNA #1 stated, I should have, if I didn't. Further interview with SRNA #1 revealed this was important to prevent the spread of infection. Interview with the Director of Nursing (DON) on 09/12/19 at 10:24 AM revealed the DON stated the purpose of contact precautions was to prevent the spread of infections. Continued interview with the DON revealed she expected all staff to follow the facility's policies and procedures. 2. Review of a facility's policy and procedure titled, Whole Blood Glucose by FreeStyle Precision Pro, dated 08/21/18, revealed the glucose meter should be handled with care. Continued review of the facility's policy revealed cleaning of the glucose meter should be performed after each patient test. However, the policy did not address the risk for potential cross-contamination of blood from the glucose meter if it touched a common surface before it had been disinfected. Observation on 09/11/19 at 11:30 AM revealed LPN #1 entered Resident #58's room to check his/her blood sugar. Continued observation revealed after LPN #1 obtained the blood sugar reading, she placed the soiled glucometer on her COW. However, LPN #1 was not observed to sanitize or disinfect the COW after she removed the glucometer from the COW. Interview with LPN #1 on 09/11/19 at 5:29 PM, revealed she did not know that she should have disinfected the COW after the soiled glucometer was removed. Interview with the DON on 09/12/19 at 10:24 AM revealed the nurse should have disinfected any surface the soiled glucose meter touched. The DON stated this was to prevent the spread of infections.

Based on observation, interview, and facility policy review, it was determined the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety. Observations of the kitchen on [DATE] revealed expired food was stored and available for use and male staff with uncovered facial hair was observed in the kitchen. The findings include: 1. Review of the facility's policy titled, Food Storage, dated [DATE], revealed all opened foods would be kept in containers that prevented contamination. Further, the policy stated containers would be clearly labeled and dated with the name of the food which it contained. The policy did not address discarding food that was beyond the expiration date. Observation of the milk cooler in the kitchen on [DATE] at 11:12 AM, revealed three 8-ounce cartons of strawberry milk with an expiration date of [DATE] were available to be served to residents. Interview with the Director of Food and Nutrition Services on [DATE] at 11:15 AM, revealed that when the milk cooler was cleaned by staff the expired milk should have been discarded. 2. Interview with the Dietary Nutritionist on [DATE] at 12:05 PM, revealed that the facility did not have a policy that addressed a dress code in the kitchen; however, staff were trained to wear hair and beard restraints in the kitchen during orientation. Observation of the entrance door to the kitchen on [DATE] at 2:35 PM, revealed a sign posted stating, NOTICE, hair net beyond this point. Further observation on [DATE] at 10:54 AM, revealed a Food Service Worker and the Chef, who both had facial hair, walked through the kitchen during preparation of the lunch meal without beard restraints. Interviews on [DATE] with the Food Service Worker at 11:54 AM, and the Chef at 11:58 AM, revealed they were aware that beard restraints were required to be worn in the food preparation area, but they were in a hurry and had forgotten to put them on. Interview with the Dietary Nutritionist on [DATE] at 10:58 AM, revealed all kitchen staff with facial hair should wear beard restraints while in a food preparation area.

Based on observation, interview, and review of medical records, facility policy, and the Long-Term Care Nursing Assistant's Mosby Textbook, it was determined the facility failed to provide appropriate treatment and services to prevent urinary tract infections for one (1) of eight (8) sampled residents (Resident #4). Observations during the provision of indwelling urinary catheter care for Resident #4 revealed the facility staff failed to clean the resident's perineum/catheter tubing in accordance with standards of practice, in an effort to prevent infection. The findings include: Review of the Long-Term Care Nursing Assistant's Mosby Textbook revealed that when cleaning an indwelling urinary catheter the catheter should be cleaned from the meatus (where urine exits the body) downward, away from the meatus about four (4) inches, with one stroke. Staff should repeat the procedure as needed with a clean area of the washcloth. A review of the facility's policy titled Perineal Care, dated 05/25/16, revealed the catheter tubing should be cleansed in a circular fashion, using a clean surface of cloth for each swipe. However, the policy did not address how to clean the catheter tubing from the meatus to the distal end of the catheter tubing. Review of the medical record revealed the facility admitted Resident #4 on 08/24/17, with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 was admitted with an indwelling urinary catheter. Review of the Comprehensive Care Plan dated 08/25/17 revealed staff would provide catheter care per the facility's policy. Observation on 09/14/17 at 10:50 AM revealed State Registered Nurse Aide (SRNA) #1 cleaned Resident #4's catheter tubing by wiping the catheter tubing toward the resident's urinary meatus. Further observation revealed when SRNA #1 rinsed the catheter tubing, she also started at the distal end of the catheter tubing and wiped toward the resident's urinary meatus. An interview on 09/14/17 at 2:45 PM with SRNA #1 revealed the SRNA had been trained to hold the catheter tubing near the meatus and clean/rinse the catheter tubing from the meatus toward the distal end of the tubing, but was nervous and did not clean Resident #4's catheter in that manner. Interview with the Charge Nurse on 09/14/17 at 3:00 PM revealed she did random spot checks when SRNAs were providing catheter care and had not identified any concerns with catheter care. Interview with the Director of Nursing on 09/14/17 at 3:10 PM revealed catheter care training was provided every two (2) years. She further revealed she also conducted spot checks when SRNAs were providing catheter care and had not identified any concerns.

Based on facility policy, observation, record review, and interview, it was determined the facility failed to maintain the kitchen in a sanitary manner. The facility failed to ensure the grease drip pan underneath the range burners was clean of grease, burned food debris, and liquid spills. The findings include: Review of the facility's policy and procedure, Food and Nutrition - Infection Control Measures, (dated 2015) revealed there was no procedure documentation for thorough cleaning of the range and grease drip pan. Observation of the range at 9:50 AM on 11/11/15 revealed the grease drip pan had an excessive accumulation of grease, burned food debris, and liquid spills. Review of the cleaning schedules revealed the grease drip pan was not listed on the schedules to be cleaned. An interview conducted with a dietary employee (chef) at 1:05 PM on 11/12/15 revealed he did not know when the grease drip pan had been cleaned. The employee stated it appeared to not have been cleaned in a while. Interview with the Food Service Director on 11/12/15 at 3:15 PM revealed the range grease drip pan was not specified on the cleaning schedule.

Based on observation, interview, record review, and review of facility policy, the facility failed to develop a comprehensive care plan for one of eight sampled residents. The facility failed to develop a care plan related to Resident #5's swallowing difficulties and need for an assistive device when drinking liquids. The findings include: A review of the facility's policy entitled Standards of Care, revised September 2009, revealed each resident's care was based on identified needs/problems and standards of care. Review of Resident #5's medical record revealed the facility admitted the resident on 11/26/13, with [DIAGNOSES REDACTED]. A review of a Nutritional Care Area Assessment (CAA) dated 12/08/13 revealed that based on a Modified [MEDICATION NAME] Swallow (MBS) test (assesses a person's ability to swallow) completed in August 2013, Resident #5 had "dysphagia" (difficulty swallowing). The CAA revealed Speech Therapy recommended staff to only provide Resident #5 thin liquids with a spoon, sips, or per Provale cup. Documentation on the CAA also revealed Resident #5 had a Provale cup at his/her bedside. A review of Resident #5's care plan revealed the facility failed to develop a care plan related to the resident's swallowing difficulties and need for an assistive device when drinking liquids. Observation of Resident #5 on 12/11/13 at 8:25 AM, during medication administration, revealed the nurse attempted to hand the resident a Styrofoam cup of liquid with a straw to drink while taking the medications. Resident #5 refused to take the cup with the straw stating, "I can't use straws, they told me not to." The nurse then removed the straw from the cup and the resident drank from the Styrofoam cup. The nurse questioned Resident #5 about not utilizing straws, and again the resident stated, "They told me not to." The nurse stated to Resident #5 that a "sign should be up in your room" to alert staff that the resident could not have straws. Further interview with Resident #5 on 12/11/13 at 3:15 PM, revealed the resident had an "x-ray of my throat" and was told he/she could not utilize straws. While pointing to a Provale cup, Resident #5 stated he/she was supposed to utilize the special cup when drinking liquids. An interview with the Registered Dietitian (RD) on 12/11/13 at 3:20 PM, revealed she was responsible for completing the Nutritional CAA and the Nutritional Care Plan. The RD stated she asked Resident #5 about swallowing problems during the assessment and notified the resident's physician that a speech therapy consultation was needed. The RD stated the resident said he/she was not having difficulties with swallowing while utilizing the Provale cup. The RD explained that a Provale cup was a "Sippy cup" type cup that kept liquids from flowing out too quickly. The RD stated she was not sure who was responsible for ensuring swallowing problems and interventions were on the resident's care plan, and assumed nursing staff was aware the resident required a Provale cup because Resident #5 had a cup at the bedside.

The facility failed to ensure expired drugs were not available for resident use. Observation of medications in the facility's crash cart (contained drugs and supplies for emergencies) on 12/11/13 revealed two vials of Norepinephrine (used in life-threatening conditions to constrict blood vessels and to increase blood pressure and blood glucose levels) that expired on 12/01/13, ten days prior to the observation. The findings include: On 12/11/13 at 4:10 PM, observations of the locked crash cart located at the nurses' station revealed a list of medications in the cart had been taped to the side of the cart along with the expiration date of each medication. Further observation revealed documentation that the Norepinephrine identified on the list had an expiration date of 12/01/13. During the course of the observation, facility staff unlocked the crash cart in order for a review of the contents to be conducted. Observation of the medications in the crash cart revealed two vials of Norepinephrine 4 milliliters (1mg/4ml) that expired on 12/01/13, ten days prior to observation, and available for use. Interview with the Director of Pharmacy on 12/01/13 at 4:30 PM, revealed staff should review the list taped to the side of the locked crash cart on a monthly basis and should remove any medications prior to the expiration date. The Pharmacy Director stated the facility had not developed written procedures or policies to ensure expired medications were removed from the cart and not available for use and had not assigned any particular person to remove drugs before they expired. However, according to the Director of Pharmacy, it was the responsibility of everyone in the Pharmacy Department to ensure drugs were removed from the crash cart before the drugs expired.

Based on observation and interview it was determined the facility failed to maintain all essential electrical equipment in safe operating condition. Observation of the chest-type ice cream freezer on 02/25/13 at 4:00 PM revealed a buildup of frost and ice around the interior walls of the freezer. The findings include: According to the "U.S. Food and Drug Administration" manual, dated 2009, Chapter 4, "Proper maintenance of equipment to manufacturer specification helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. For example, refrigeration units in disrepair may no longer be capable of properly cooling or holding potentially hazardous (time/temperature control for safety) foods at safe temperatures." Observation of the facility ice cream chest-type freezer during the final sanitation audit on 02/25/13 at 4:00 PM revealed a thick buildup of frost and ice located on the interior walls of the chest-type freezer. The facility's Dietitian acknowledged in interview conducted on 02/25/13 at 4:00 PM the freezer needed to be defrosted. The facility Dietitian further stated he/she could not remember when the freezer had been defrosted last.

Based on observation and interview the facility failed to ensure foods stored in the facility were safe for consumption. Five dented cans containing food products from a food distributor were observed to be stored with regular food stock and available for use. The facility failed to ensure the food products were stored to maintain the integrity of packaging until they were ready for use. The findings include: According to the "U.S. Food and Drug Administration" manual, 2009, Chapter 3, "FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted and pitted or dented cans may also present a serious potential hazard." During the sanitation audit conducted on 02/25/13 at 4:00 PM, five dented cans of food products (two cans of pineapple slices, two cans of tomatoes, and one large can of chicken noodle soup) were observed in the facility food stock room and available for use to serve to the residents. An interview was conducted at 4:15 PM on 02/25/13 with the facility's Dietitian. The Dietitian stated the dented cans had a breached seal and acknowledged the food products in the dented cans should not have been available for resident use.

Based on observation, interview, record review, and policy review, it was determined the facility failed to follow physician's orders for one of five sampled residents (Resident #3). A physician's order dated 03/07/12 revealed Resident #3 was not to drink liquids with a straw, however, on 03/13/12, a bottle of Ensure (dietary supplement) was observed on the resident's bedside table, within the resident's reach, and a straw was observed in the bottle of Ensure. The findings include: A review of the policy titled, "Care Planning/ Interdisciplinary," (with a revision date of November 2004) revealed an initial plan of care was generated from the admission history and assessment for each resident. The policy also revealed the plan of care would be individualized, addressing identified resident needs, and would also contain any problems that had been identified by any discipline as a result of an initial assessment or from subsequent reassessments. A review of the medical record for Resident #3 revealed the facility had admitted the resident on 03/07/12 with [DIAGNOSES REDACTED]. A review of the admission orders [REDACTED]. The physician's order also revealed the head of the resident's bed should be elevated 90 degrees during meals and for 30 minutes after eating. A review of a report of a Modified [MEDICATION NAME] Swallow completed on 02/22/12, revealed a recommendation for the resident to receive chopped mechanical soft foods with ground meats and gravy, small sips of thin liquids, and straws were not recommended due to an increase in the resident's pharyngeal residue (food and liquids left in the pharynx after swallowing). The report also revealed the resident was required to sit upright at 90 degrees during meals and for 30 minutes after having any oral intake. A review of the Comprehensive Care Plan for Resident #3 dated 03/07/12 revealed the resident required a Mechanical Soft diet. However, there was no documentation on the care plan that indicated Resident #3 was restricted from the use of straws with liquid drinks. A review of a nutritional assessment completed on 03/08/12 by the Registered Dietitian (RD) revealed the resident had been assessed to have difficulty swallowing and chewing. The RD recommended to continue the resident on the same diet and to maintain the current therapy. Observation of Resident #3 during the initial tour on 03/13/12, at 10:20 AM, revealed the resident had a sign posted above the head of the resident's bed which stated to keep the head of the bed elevated at 90 degrees during oral intake and for 30 minutes after eating. The sign also indicated Resident #3 was to have small bites of food when eating and was not to use straws for drinking. However, observation revealed a bottle of Ensure was on the resident's bedside table, within the resident's reach, and a straw was observed in the bottle of Ensure. An interview conducted with Certified Nursing Assistant (CNA) #2 on 03/13/12, at 11:35 AM, revealed the CNA provided care for Resident #3 and acknowledged the resident should not have straws provided with liquid drinks. The CNA stated she was unaware of how the resident acquired the straw. An interview conducted with Licensed Practical Nurse (LPN) #1 on 03/13/12, at 2:35 PM, revealed the LPN provided care to Resident #3 on 03/13/12 and stated the resident drank Ensure with a straw on that date. The LPN stated she obtained information related to resident care from the care plan and also from the Kardex which was used to relay information to the next shift. The LPN also stated it was the responsibility of the nurse to update the care plan and stated she was unaware of the physician's order for Resident #3 to not have straws. An interview conducted on 03/15/12, at 5:50 PM, with the facility's Registered Dietitian (RD) revealed she developed the nutritional portion of the care plan. The RD stated she had failed to review the physician's orders and, as a result, failed to develop an intervention on the care plan related to the physician's request to restrict the use of straws for the resident when the resident received liquids. An interview conducted with the Director of Nursing (DON) on 03/15/12, at 5:55 PM, revealed the care plan should state exactly what was going on with the resident. The DON stated Resident #3's care plan should have reflected the resident was not to drink fluids with a straw. The DON further stated she reviewed all medical records, including the care plans, three times every week for accuracy but had failed to identify that Resident #3's care plan was not accurate.

Based on observation, interview, record review, and policy review, it was determined the facility failed to establish and maintain an effective infection control program to prevent the development and transmission of disease and infection for one of five sampled residents (Resident #1). Observation of wound care on 03/14/12 revealed the nurse failed to wash/sanitize her hands between glove changes. The findings include: A review of the facility policy titled, "Hand Hygiene," (with a revision date of 11/20/08) revealed staff was required to decontaminate hands after removing gloves, with either plain or antiseptic-containing soap and water, or the use of alcohol based products that do not require the use of water. A review of the medical record for Resident #1 revealed the facility had admitted the resident on 01/07/12, with [DIAGNOSES REDACTED]. Observation of wound care for Resident #1 on 03/14/12, at 1:25 PM, revealed Registered Nurse (RN) #1 washed/sanitized her hands and applied gloves prior to wound care. RN #1 was then observed to remove a soiled dressing from the wounds to the upper buttocks of Resident #1, discard the dressings in the trash, remove her soiled gloves, and apply clean gloves. RN #1 failed to wash/sanitize her hands after removing soiled gloves and prior to applying clean gloves. Continued observation revealed RN #1 cleansed the wound to the resident's left upper buttock with a cleansing solution and a 4x4 gauze sponge. The RN disposed of the soiled gauze sponge in the trash, removed her gloves, and applied clean gloves but failed to wash/sanitize her hands between glove changes. The RN was then observed to cleanse the wound to the resident's right upper buttock with a cleansing solution and a 4x4 gauze sponge, placed the soiled gauze sponge in the trash, removed her soiled gloves, and placed them in the trash. The nurse was observed to apply clean gloves without washing/sanitizing her hands. At that time, the RN was observed to apply a skin protectant paste to the area of skin surrounding the wound of the left upper buttocks using a cotton swab. The RN disposed of the cotton swab in the trash, removed her gloves, and placed them in the trash, applied clean gloves, and failed to wash/sanitize her hands. The RN then applied a skin protectant paste to the right upper buttock wound with a cotton swab, disposed of the cotton swab in the trash, applied clean gloves, and failed to wash/sanitize her hands. Continued observation of the wound care revealed the RN applied a normal saline soaked dressing to the wound of the left upper buttock, disposed of gloves in the trash, applied clean gloves, and failed to wash/sanitize her hands. The RN was then observed to apply a normal saline soaked dressing to the wound of the right upper buttock, dispose of the gloves in the trash, apply clean gloves, and failed to wash/sanitize her hands. The RN was then observed to cover the wound to the left upper buttock with a dressing, dispose of the soiled gloves in the trash, apply clean gloves, and failed to wash/sanitize her hands. The RN then applied a dressing to the wound to the right upper buttock, disposed of her gloves in the trash, and washed/sanitized her hands. An interview conducted with RN #1 on 03/15/12, at 11:45 AM, revealed the RN was not aware she was required to wash/sanitize her hands after removing gloves. The RN stated she thought changing her gloves had been sufficient and to wash/sanitize her hands when the wound care had been completed. The RN stated she had completed in-services provided by the facility on hand washing and wound care, however, she did not remember what the in-service had covered. An interview with the Infection Control Nurse (ICN) on 03/15/12, at 1:40 PM, revealed hand hygiene should be done any time an employee changes his/her gloves. The ICN also stated she had not previously identified this as a problem. The ICN revealed hand hygiene was a part of all employees' initial orientation and was also completed on an annual basis. An interview conducted with the Director of Nursing (DON) on 03/15/12, at 3:40 PM, revealed employees were expected to wash/sanitize their hands after changing gloves. The DON revealed she conducted "spot checks" to monitor staff for proper hand washing and had not observed concerns related to staff failing to wash hands between glove changes. The DON confirmed staff was to wash/sanitize their hands after every glove change.

Based on observation, interview, and a review of the facility's policy, it was determined the facility failed to provide care that promoted the resident's dignity and respect for five of five sampled residents (Residents #1, #2, #3, #4, and #5). Observation of the lunch and supper meals on 03/13/12 revealed all residents were delivered meal trays that had plastic disposable silverware and disposable food containers. The findings include: A review of the policy titled, "Resident Rights," (no date) revealed residents have the right to be treated with dignity and respect as an individual who has personal needs, feelings, preferences, and requirements. The policy also stated the residents have the right to a dignified existence. Observation of the lunch meal service on 03/13/12, at 12:00 PM, revealed ten meal trays (including the trays for the five sampled residents) were on the tray cart and all ten trays had plastic disposable eating utensils on the trays. The trays were also observed to have dessert in plastic disposable containers. Observation of the supper meal service on 03/13/12, at 5:20 PM, revealed ten meal trays (including the trays for the five sampled residents) were observed on the meal cart and all ten meal trays were observed to have plastic disposable eating utensils on the trays. The trays were also observed to have dessert in disposable plastic containers. An interview conducted on 03/13/12, at 3:20 PM, with the Hospital Assistant Administrator (HAA) revealed the HAA was responsible for overseeing the Dietary Department. The HAA stated he was unsure why the facility was using disposable eating utensils. The HAA stated it may have been a timesaving issue because the staff could grab a packet of silverware and place it on the tray. An interview conducted on 03/13/12, at 3:45 PM, with the Dietary Manager (DM) revealed the facility had silverware and regular dishes that could be sent up on the food trays. A group interview conducted on 03/14/12, at 10:00 AM, with four residents (Resident #1, Resident #3, and unsampled Residents #6 and #7) who had been assessed by the facility to be interviewable revealed the residents had received plastic silverware and disposable plastic food containers on every meal tray. The residents stated it was not homelike and that they would like to have regular silverware and dishes, however, the residents stated they had not reported their concern to the facility. An interview conducted with the Administrator on 03/14/12, at 2:45 PM, revealed the Administrator had been aware regular silverware and dishes should have been used instead of plastic silverware and disposable plastic containers; however, the Administrator revealed she had not attempted to correct the problem. The Administrator stated she was unsure how long the facility had been using plastic silverware and disposable containers but that it had been for a while.

Based on observation, interview, and a review of facility policies, the facility failed to distribute and serve food under sanitary conditions to residents. During the noon meal on May 24, 2011, facility staff was observed to distribute/serve trays to six of twelve residents. The food items (grapes, tossed salad, pears, and cake) served to the residents were observed to be uncovered. The findings include: A review of the facility's Tray Delivery policy/procedure (reviewed by the facility on June 7, 2010) revealed resident trays were to be delivered to the resident areas as rapidly as possible after the trays were assembled in the kitchen. The policy noted Nursing Services was to be notified when the trays arrived at the Unit and the trays were to be transported/delivered to the residents in a closed cart to ensure food temperatures were maintained and to keep foods sanitary. Observations during the noon meal on May 24, 2011, revealed the closed meal cart was delivered from the kitchen to the resident floor at 11:55 a.m., and was placed in the hallway near room 361. Two staff members were observed to begin passing trays to the residents. At 12:04 p.m., a resident tray was removed from the food cart and was transported by facility staff to room 362 (approximately 10 feet) from the food cart. The tray was observed to contain an uncovered dish of grapes. The facility staff was observed to push the food cart down the hallway and place the cart near the nurses' station. At 12:05 p.m., facility staff was observed to remove a tray containing an uncovered dessert and salad from the food cart and carry the tray to the resident's dining room located approximately 70 feet from where the cart was parked. The staff continued to distribute resident trays without moving the food cart from the location near the nurses' station and at 12:07 p.m., a resident's tray was delivered to room 366 (approximately 50 feet from the food cart) and contained a bowl of uncovered pears. At 12:10 p.m., staff was observed to deliver a tray to room 367 (approximately 26 feet from the food cart). The tray contained an uncovered bowl of grapes and tossed salad. At 12:12 p.m., staff was observed to deliver a tray containing an uncovered slice of cake to room 369 (approximately 54 feet from the food cart). At 12:14 p.m., a tray was observed to be delivered to room 371 (approximately 80 feet from the food cart sitting near the nurses' station). The tray contained an uncovered dish of pears. An interview conducted with Registered Nurse (RN) #1 on May 24, 2011, at 12:23 p.m., revealed the closed food cart should be pushed down the hallway and stopped near each resident's room to ensure food items remained sanitary during delivery. An interview conducted with Certified Nurse Aide (CNA) #1 on May 24, 2011, at 3:20 p.m., revealed the food cart was to be moved from room to room during tray delivery to the residents. CNA #1 stated food items should not be transported past the food cart without the items being covered. The Director of Nurses (DON) stated in an interview conducted on May 25, 2011, at 11:05 a.m., the facility practice was to move the food cart from room to room to ensure foods were delivered to the residents in a sanitary manner. The DON stated staff had not followed the routine tray delivery process during the noon meal on May 24, 2011.

Based on interview, medical record review, and facility policy review, it was determined the facility failed to develop a comprehensive care plan for two of eight sampled residents (residents #2 and #6) related to the residents' history of a positive [MEDICATION NAME] (TB) skin test. The findings include: A review of the facility's Care Plan policy/procedure (revised September 1, 2009) revealed the resident's plan of care would contain problems that had been identified by any discipline as a result of the initial assessment or subsequent reassessment of a resident. The policy further noted the plan of care would include consideration of the physical, psychosocial, environmental, nutritional, self-care, educational, and discharge planning factors that affected the resident's care needs. 1. A review of the medical record revealed resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the facility's [MEDICAL CONDITION] Screening Sheet dated May 19, 2011, revealed the resident had been identified to have a history of a positive TB skin test. A review of the resident's comprehensive care plan dated May 19, 2011, revealed no evidence the facility had developed a plan of care to address resident #2's history of the positive TB skin test to include monitoring the resident for signs and symptoms of active disease. An interview conducted with the Minimum Data Set (MDS)/Care Plan Coordinator on May 25, 2011, at 2:30 p.m., revealed she was responsible to develop/update a plan of care for each resident after the comprehensive assessment had been completed. The MDS/Care Plan Coordinator stated the admitting nurse was responsible for the development of the initial plan of care for the residents. The MDS/Care Plan Coordinator further stated care plans had been developed to address residents with a history of positive TB skin test. 2. A review of the medical record revealed resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further record review revealed a [MEDICAL CONDITION] (TB) Screening was conducted upon admission for resident #6. The screening identified resident #6 to have a history of a positive TB skin test. The screening further noted the resident had [MEDICAL CONDITION] "[AGE] years ago." However, a review of the resident's plan of care initiated on May 6, 2011, revealed no evidence the facility had developed a plan of care to address the resident's history of positive TB. An interview conducted with the Director of Nurses (DON) on May 25, 2011, at 6:00 p.m., revealed the facility had not developed a plan of care to monitor residents identified with a history of a positive TB skin test. The DON stated the resident was monitored daily through lung assessments for any symptoms of active lung disease.

Based on record review, interview, and a review of facility policies, the facility failed to ensure pharmacy irregularities were reported to the attending physician for two of eight sampled residents. The findings include: A review of the facility policy/procedure related to the Drug Regimen Review (reviewed by the facility on September 2009) revealed drug regimen review recommendations would be reported to the physician and the Director of Nurses (DON) within seven working days of the medication review. The policy noted the physician and nursing personnel would provide a written response to the pharmacist's review/report and a copy of the report would be maintained by the facility. 1. A review of the medical record for resident #5 revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the current physician's orders revealed resident #5 had orders to receive Lasix 40 milligrams (mg) daily, Micro K 10 micrograms (mcg) daily, Synthroid 25 mcg daily, and Zocor 80 mg daily. A review of the medication regimen review conducted on May 16, 2011, revealed the consultant pharmacist made recommendations to the physician to update resident #5's lipid panels and thyroid-stimulating hormone (TSH) levels. The consultant pharmacist noted the most recent lab tests available were in 2002. However, there was no evidence the physician or Nursing Services had reviewed/acted upon these recommendations. An interview conducted with Registered Nurse (RN) #1 on May 25, 2011, at 2:10 p.m., revealed nurses were responsible to review the pharmacy review/recommendations and to ensure the recommendations were reviewed by the resident's physician. Based on the interview, the resident's physician acknowledged receipt/review of the pharmacist's recommendation by the physician's signature on the recommendations. RN #1 stated based on documentation the pharmacy recommendations for resident #5 had not been reviewed by the resident's attending physician. 2. A review of the medical record revealed resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the current physician's orders revealed resident #6 had orders to receive Coumadin (anti-coagulant) 5 mg daily, Coreg (anti-hypertensive) 3.125 mg (2 tabs) twice a day, and Indomethacin (non-steroid anti-inflammatory drug) 25 mg daily. A review of the medication regimen review conducted by the consultant pharmacist on May 9, 2011, revealed the pharmacist recommended to "consider" the risk of gastrointestinal (GI) bleeding with the use of Indomethacin and Coumadin. The pharmacist noted Indomethacin would also decrease the anti-hypertensive effect of Coreg more than other non-steroid anti-inflammatory drugs (NSAIDs). The pharmacist recommended the physician consider "switching" resident #6 to an alternate NSAID other than Indomethacin. However, there was no evidence the resident's physician or Nursing had acted upon or reviewed this recommendation for resident #6. An interview conducted with the Director of Nurses (DON) on May 25, 2011, at 2:50 p.m., revealed the medication regimen reviews should be left on the resident's chart for the physician and Nursing to review. The DON stated the nurse was responsible to call the resident's attending physician to follow up on the pharmacist's recommendations if the physician failed to sign the medication regimen review.

Based on interview and record review, the facility failed to protect the discharge rights of one (1) of seven (7) sampled residents. Resident #1 was admitted to the facility on [DATE], and was discharged on [DATE]. The resident and family were not notified in writing, prior to the discharge, of the right of appeal and other written discharge notice requirements. The findings include: A review of the medical record for resident #1 revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the physician's Discharge Summary dated July 27, 2010, revealed resident #1 was able to tolerate light physical and occupational therapy but did not make much progress from a functional standpoint due to a physician-ordered non-weightbearing status, pain, and motivation. The resident had been having periods of orthostatic [MEDICAL CONDITION] secondary to volume depletion, and autonomic [MEDICAL CONDITION]. The orthostasis had improved significantly prior to the resident's discharge. Resident #1 was transferred on July 27, 2010, to a swing-bed unit at a local hospital due to non-weightbearing status and the continued need for medical monitoring. An interview was conducted with resident #1's daughter on September 28, 2010, at 9:30 a.m. The resident's daughter stated the Social Worker/facility staff had not provided resident #1 or the family with a written notice of discharge to provide the resident/family knowledge of the Resident Rights of appeal prior to the resident's transfer/discharge on July 27, 2010. An interview was conducted with the facility Director of Nursing (DON) on September 27, 2010, at 12:30 p.m. The DON stated the facility was aware of the resident's/family's dissatisfaction with resident #1's transfer/discharge on August 2, 2010. The DON stated an investigation was initiated at that time. The DON stated that the facility had initiated a new discharge form to provide a written notice to residents/families at the time of a resident's discharge. The DON was unable to locate/provide the surveyor with documentation of a written discharge notice provided prior to resident's #1's discharge/transfer on July 27, 2010.