NEWNAN, GA-ANSLEY PARK HEALTH AND REHABILITATION

MEDICATION CARTS

Based on observation, interview, and facility policy review, the facility failed to ensure one of three medication carts were locked when not under the direct control of a licensed nurse. The failure could have led to residents or unauthorized staff having access to medications stored in the medication cart.

Findings include:
Observation of the 100-hall on 04/28/22 at 8:43 AM revealed an unlocked medication cart pushed against the wall with the drawers facing the hallway. The cart was against the wall to the right of Resident (R) 36’s room with no nurse or medication aide in the area. Licensed Practical Nurse (LPN) 1 was observed down the hall entering R138’s room with medications. LPN1 was away from the cart for four minutes, during which the cart was not under the direct supervision or sight of an employee with the qualifications to supervise a medication cart.

At 8:47 AM on 04/28/22, LPN1 returned to her medication cart, she locked the cart as this surveyor approached her to conduct an interview. During the interview at 8:48 AM on the same day, LPN1 stated the cart should have been locked before she walked away from it. When asked why the cart had not been locked, she replied, I forgot to double check myself. LPN1 confirmed the cart should have been locked before she walked away to administer R138’s medications or when she was not physically in the presence of the medication cart.

During an interview on 04/28/22 at 9:32 AM, the Director of Nursing (DON) stated her expectation was that the medication cart should have been locked before LPN1 walked away to administer medications. The DON confirmed medication carts were to be locked when unattended or not under the direct supervision of the nurse or medication aide assigned to the medication cart.

Review of the facility policy titled, Pharmacy Services Medication Administration-General with a copyright date of 2019 stated, . During routine administration of medications, the medication cart is kept locked or under direct observation of licensed staff .

COVID-19 & P.P.E

Based on observation, interview. and record review, the facility failed to have all personal protective equipment (PPE) readily available for staff use for one of one resident (Resident (R) 137) reviewed for transmission-based precautions. Additionally, PPE that was readily available was stored for use in the patient room where it could become contaminated. R137 was in quarantine due to being a new admission and unvaccinated for coronavirus disease 2019 (COVID-19). This failure had the potential to allow spread of
infections, including COVID-19, to 22 residents on the first floor who were cared for by the same staff as R137.

Findings include:
During an observation on 04/25/22 at 10:30 AM, one resident (R137) was located in the COVID-19 quarantine unit. The quarantine unit was located on the first floor at the end of the hallway. The quarantine unit was blocked off from the other residents by a plastic wall with a doorway. There were three signs placed on R137’s door stating, STOP Droplet Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry or Remove face protections before room exit; STOP Contact Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person .; COVID-19
Personal Protective Equipment (PPE) for Healthcare Personnel Preferred – Use N95 of Higher Respirator Face shield or goggles, N95 or higher respirator, Isolation gown, one pair of clean non-sterile gloves . There
was not any PPE or hand sanitizer located immediately outside of R137’s room or in the hallway. The door to R137’s room was open and on a table inside the room were several gowns. Surveyor looked in the adjacent
two rooms and there was no PPE readily available for use. One of the rooms was being used as a storage room and had numerous boxes in it, but the surveyor was unable to determine what was in the boxes. Surveyor left the quarantine area to locate a staff member to discuss the lack of PPE in the quarantine unit.

During an interview on 04/25/22 at 10:38 AM, with Licensed Practical Nurse (LPN) 2, when asked about the PPE on the quarantine unit, LPN2 noted there were some gowns in R137’s room and stated additional PPE
must be the adjacent room. LPN2 went into the adjacent room and looked around but could not locate PPE that was readily available for use. LPN2 acknowledged the PPE should be available to don prior to entering
R137’s room. LPN2 left the quarantine unit and returned carrying a PPE door hanging unit with filled with PPE but stated she did not have access to the stickers to enable her to hang the holder on R137’s door. LPN2 left the unit and returned with a rolling bedside table and laid the door hanger on the table. Surveyor questioned how staff were to sanitize their hands prior to donning gloves (there was no sanitizer located in the hallway) and LPN 2 stated she would obtain the hand sanitizer. Surveyor questioned LPN2 who was responsible for placing the required PPE for a resident who was under quarantine, and she said replied,
Anybody.

During an interview on 04/25/22 at 10:45 AM, on the quarantine unit, the Director of Nursing (DON) said she was surprised the PPE had not been available for staff to don prior to entering R137’s room. The DON stated
there was a red cart stocked with PPE that should have been placed outside of R137’s room and she did not know why the staff did not utilize the cart. The DON stated she was responsible to ensure that PPE was in place for use with a resident on the quarantine unit.

Review of R137’s EMR under the Face Sheet tab indicated R137 was admitted to the facility on [DATE] with the diagnoses of wedge compression fracture third lumbar vertebra, chronic bronchitis, age related osteoporosis, abnormalities of gait and mobility and underweight.

Review of R137’s EMR under the Orders tab indicated an order 04/24/22 droplet precautions 9 days, diagnosis: COVID screening, start date 04/24/22 end date 05/02/22

Review of R137’s EMR under the Test Results tab revealed R137 received COVID-19 tests on 04/22/22 and 04/24/22 and both test results were negative.

Review of the facility’s policy titled, Admission and Placement of Patients dated 02/22 stated, Purpose To provide guidance to centers regarding admission and readmission of patients during COVID-19 pandemic Managing New Admission and Re-Admission Patient Placement . 2. New admissions . whose COVID-19 status is unknown or not up to date on all recommended COVID_19 vaccine doses should be placed in the
observation unit. 3. New admissions regardless of vaccination status should have a series of two viral test for SARS-Cov-2 infection; immediately .
Review of the facility’s policy titled Transmission-Based Precautions (Contact, Enhanced Barrier Precautions, Droplet, Airborne) dated 2020 stated, Intent It is the policy of this facility to use transmission-based precautions for patients who have infectious or communicable diseases that may necessitate the use of barriers in addition to those used for Standard Precautions . Contact Precautions This facility uses Contact Precautions . for patients with known or suspected infection . with highly transmissible . pathogens for which additional precautions are needed to prevent transmission . Use of PPE Gloves . Gowns . Droplet Precautions This facility uses Droplet Precautions as recommended . for patients with known or suspected to be infected with pathogens transmitted by respiratory droplets . Use of PPE . For patients with suspected or proven . pandemic influenza refer to the following websites for the most current recommendations at the time (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.Html .