146113
10/14/2022
Greenup Rehab and Nursing
300 North Marietta Street Greenup, IL 62428
F 0661
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Based on record review and interview the facility failed complete the recapitulation of stay, discharge summary and failed to implement a discharge plan of care for one (R37) resident out of one resident reviewed for discharge in a sample list of 22 residents.
Findings include: R37's Undated Face Sheet documents an admission date of 6/19/22 and discharge date of 8/1/22. R37's Comprehensive Care Plan does not include a focus area, goal nor interventions for discharge. R37's Medical Record does not include a recapitulation of stay summary nor any copies of information sent with R37 at time of discharge. R37's Interdisciplinary Team meeting and Social Service progress notes do not include discharge summary information. On 10/13/22 at 12:11 PM V3 Social Service Director (SSD) stated I did not know a recapitulation of stay needed to be completed. I have not done one of those for any of the discharges since I have worked here. There is no summary of any kind. (R37) was admitted to facility for a short-term rehabilitation stay and planned to return to home after therapy released (R37). (R37) was sent home with home health services, medications as prescribed, and therapy was to continue. I set all this up for (R37) but did not write any of it down. I guess I should have looked back.
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146113
146113
10/14/2022
Greenup Rehab and Nursing
300 North Marietta Street Greenup, IL 62428
F 0812
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Based on observation, interview, and record review, the facility failed to prevent the potential for chemical cross-contamination in the kitchen dishwashing sinks. This failure has the potential to affect all 37 residents residing in the facility.
Findings include: On 10/11/2022 at 10:40AM, the kitchen three-basin sink had a floor cleaner chemical dispenser mounted directly above the center basin of the sink with the outlet tubing coiled into and resting on the bottom of the third basin of the sink. A container of chemical floor cleaner supplied the dispenser and was not labeled for use with food contact surfaces. A chemical dispenser supplying food-grade dish detergent and sanitizer was plumbed in series downstream from the floor cleaner dispenser. On 10/11/2022 at 11:58AM, V6 (Dietary Aide) reported the floor cleaner dispenser is used daily to dispense chemicals into a mop bucket for floor cleaning. On 10/13/2022 at 11:50AM, V6 reported the sink basin the floor cleaner dispenser outlet hose was resting into was used for sanitizing dishes. On 10/13/2022 at 12:10AM, V7 (kitchen sanitation chemical supply contractor) reported the floor cleaner chemical dispenser would usually be plumbed into a utility mop sink, and not into a three-basin dishwashing sink. On 10/13/2022 at 12:45PM, V5 (Dietary Manager) reported V5 was not 100% sure if the floor cleaner dispenser above could cross-contaminate the sink basin where dishes are washed. The floor cleaner Safety Data Sheet (7/19/2013) documents May cause nausea and May cause damage to mucous membranes and tissue. The facility Resident Census and Conditions of Residents report (10/11/2022) documents 37 residents reside in the facility.
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146113
10/14/2022
Greenup Rehab and Nursing
300 North Marietta Street Greenup, IL 62428
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm or potential for actual harm
Based on observation, interview and record review facility staff failed to prevent cross contamination during urinary catheter care for 1 (R6) of 1 resident reviewed for urinary catheter care in a sample of 22 residents.
Residents Affected - Few
Findings include: V16, Certified Nurses Assistance (CNA) was observed on 10/13/22 at 1:11 PM doing urinary catheter care for R6. During the procedure, V16 washed her hands, donned on gloves to continue with her procedure of urinary catheter care. V16 then reached over and pulled V16's sweatshirt left sleeve up to the elbow and then bent over to touch the bed control and to raise the bed up to complete care. V16 did not remove the contaminated gloves. V16 continued on performing urinary catheter care with contaminated gloves on. V16 set the plastic bag with dirty wash clothes on the floor and realized what she did and picked the plastic bag up from the floor and put it on the bottom of the bed V16 had the same gloves on while performing the urinary catheter procedure. After completing care for R6's perineum area , V16 removed her gloves used hand sanitizer and donned on a new pair of gloves. V16 turned R6 over to complete the urinary catheter care. V16 stated she was done and did not clean the catheter tubing for R6. V2, Director of Nurses (DON) stated in interview on 10/13/22 at 1:30 PM Yes, V16 came in here and told me she messed up the urinary catheter care and failed to clean the Foley catheter tubing. The facility's policy titled Catheter Care reviewed February 2018, states for the procedure for females to wash your hands, apply clean gloves, then continue with care to #7 which states Wash the catheter tubing from the opening of the urethra outward 4 inches or farther if needed. Do not pull on the catheter. Facility policy titled Handwashing dated 12/2018 states All staff will wash hands, as washing hands as promptly and thoroughly as possible after resident contact and after contact with blood, body fluids, secretions, excretions, and equipment or articles contaminated by them is an important component of the infection control and isolation precautions.
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