Sprenger Healthcare of Bluffton

In the surveyor’s words

From the most serious findings on record at Sprenger Healthcare of Bluffton, in the surveyor’s own words.

• Immediate jeopardy, isolatedF880Nov 19, 2022

  Based on observations, interviews, record review, manufacturer's instructions, and facility policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: - Ensure multi-use glucometers were cleaned and disinfected after each use by 2 of 3 nurses observed during medication pass, which had the potential to affect 10 residents with orders for blood glucose monitoring. - Ensure proper hand hygiene and glove use when obtaining blood for glucose monitoring by 1 of 3 nurses observed during medication pass. […]

• Actual harm, isolatedF760May 29, 2022

  Based on record review, interviews, and review of the facility policy, the facility failed to administer medications per physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Specifically, Resident (R)10 was administered [MEDICATION(S)] (a sleeping pill used to treat [CONDITION(S)]) 40 mg on [DATE] and [MEDICATION(S)] (medication used to treat low blood pressure) 5 mg x 4 tablets (20 mg) at bedtime on [DATE], [DATE], [DATE] and [DATE]. This deficient practice placed the resident at risk for adverse outcomes due to being over medicated by staff. […]

• No harm, potential for more than minimal, widespreadF761Jul 30, 2021

  Based on observation, interview and record review, the facility failed to double lock and secure Scheduled IV controlled medications in a permanently affixed compartment in two (2) of 2 medication rooms. The medication room refrigerator had no locking device to secure three (3) Lorazepam ([MEDICATION(S)]) syringes and thirty-five compound syringes of [MEDICATION(S)] (Lorazepam), [MEDICATION(S)], [MEDICATION(S)] (ABH) gel. Findings: The facility did not provide a Controlled Drug policy. On 7/29/21 at 8:49 a.m., observation of the Memory Care medication storage room refrigerator with Licensed Practical Nurse (LPN) #2, revealed the medication room had a locked entry door. However, the refrigerator inside the medication room was unlocked. […]

• No harm, potential for more than minimal, widespreadF812Jul 30, 2021

  Based on observation, interviews, record review, and review of facility policy, the facility failed to label and date food containers when opened, failed to close the food packages/boxes when opened, failed to air dry the steam table pans, failed to change gloves when touching food and failed to handle the plates and bowls in a sanitary manner. Findings include: Review of the facility policy titled; Food Storage dated 2018 documented: 1.d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. 1.e. Store scoops covered in a protected area near the food containers. 3.e. […]

• No harm, potential for more than minimal, patternF759Nov 19, 2022

  Based on observations, record review, interviews, document review, and facility policy review, the facility failed to have a medication error rate of 5% or less. The facility had 7 errors out of 28 observations for a medication error rate of 25%. This affected 3 out of 7 residents reviewed during the medication observation task. Findings included: 1. On 11/18/22 at 11:10 AM, the Director of Nursing (DON) stated the facility did not have a specific policy for insulin administration but stated they followed the medication administration policy. […]