LOCATED: 201 KIMBERLY LANE, WILLIAMSTOWN, KY 41097
GRANT CENTER was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:
PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.
FACILITY FAILED TO HAVE AN EFFECTIVE SYSTEM TO ENSURE THE RESIDENTS’ ENVIRONMENT REMAINED AS FREE OF ACCIDENT HAZARDS AS POSSIBLE
LEVEL OF HARM – IMMEDIATE JEOPARDY
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview, record review, and review of the facility’s policy and Incident Report it was determined the facility failed to have an effective system to ensure the residents’ environment remained as free of accident hazards as possible. The facility failed to have procedures in place to ensure all lab specimens were stored in a safe secure area to prevent resident access for one (1) of three (3) sampled residents (Resident #1). (Refer to F281) On 10/19/13 at approximately 9:00 AM, Resident #1, who was sitting in a wheelchair in front of the Heritage Unit nursing station, was observed by a nurse to have a lab specimen tube of blood with the stopper removed, holding the tube to his/her mouth. Resident #1 had a red substance in his/her mouth; on his/her face and hands; on the blanket covering Resident #1’s upper leg area; and, on the floor beside his/her wheelchair. A second lab specimen tube of blood was lying on the floor near Resident #1’s wheelchair, and the biohazard specimen bag was lying on the blanket covering the resident’s upper leg area. Resident #1 was assessed and laboratory tests were obtained for both Resident #1 and the resident from whom the specimen was drawn. Based on the results of the assessment and tests no negative impact on Resident #1 had been identified. The facility’s failure to ensure the residents’ environment remained as free of accident hazards as possible was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 10/30/13, and was determined to exist on 10/19/13.
Continuing: Interview, on 10/30/13 at 5:20 PM, with Registered Nurse (RN) #3 revealed she was the night shift nurse who had obtained the two (2) tubes of blood from another resident on another unit on 10/19/13. She stated that she had taken the two (2) tubes of blood to Resident #1’s unit because the resident she had drawn the blood from also had a urine specimen to be picked up which was located in a refrigerator on the unit where Resident #1 resided. She indicated that way all the specimens would be in the same area for the lab pick up. According to RN #3, she handed the specimen bag with the two (2) tubes of blood in it to LPN #5 on Resident #1’s unit. She stated there was never a specific place for staff to put lab specimens waiting for lab pick up.
Continuing: Interview, on 10/30/13 at 4:15 PM, with the Administrator revealed he was notified of the incident involving Resident #1 at approximately 9:00 AM on 10/19/13. He indicated he was informed by staff it had always been the process to store lab specimens on the desk at the nurse’s station to await lab pickup. According to the Administrator, he had not been aware staff was using this process for lab specimens until the incident involving Resident #1. He reported the process had been changed since the incident. The Administrator stated he thought processes, for lab specimens awaiting pickup, had been developed by the former DON who left the facility in September 2013.
Personal Note from NHAA Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.
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