Albany County Nursing Home

Deficiency Details, Complaint Survey, September 4, 2012

PFI: 0030
Regional Office: Capital District Regional Office

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F323 483.25(h): FACILITY IS FREE OF ACCIDENT HAZARDS

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: October 19, 2012

The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.

Citation date: September 4, 2012

Based on observation and staff interview, the facility did not ensure that the the resident environment remained as free of accident hazards as possible on three of three units observed during a complaint investigation (Case #NY00119014). Specifically, on one unit a linen cart was observed to have a razor with the blades exposed lying on top and a storage room was unlocked and the door was propped open and residents were ambulating and/or moving in wheelchairs within three feet of both hazards. On three of three units, treatment carts were observed to be unlocked and unattended with residents ambulating and/or moving in wheelchairs within three feet of the carts. This resulted in no harm with the potential for more than minimal harm that is not immediate jeopardy. This was evidenced by the following:

Finding 1:
A linen cart was observed to have a razor with the blades exposed lying on top and a storage room was unlocked and the door was propped open.

During an observation on 8/30/12 at 9:05 am, a linen cart was observed in the hallway. There were six residents observed to ambulate by the cart with one resident observed to sit next to the cart. On top of the linen cart was a basin that held supplies including razors, one of the razors was observed to not have the protective plastic over the blades and the blades were exposed and lying on top of the supplies.

During an interview on 8/30/12 at 9:06 am, Certified Nursing Assistant (CNA) #1 stated that she was not aware that there was an open razor on top of the cart and that it should not have been left there because it could be dangerous to the residents. The CNA looked around the hallway and stated that five of the six residents near the cart were often confused and that it would not surprise her if any of them were to go through items on the cart.

During an interview on 8/30/12 at 9:39 am, the Director of Nursing (DON) stated that razor blades should not have been stored on the linen cart in the hallway and that an open razor should not have been left in a common area where residents could have potentially gotten to it.

Finding 2:
A storage room was unlocked and the door was propped open.

During an observation on 8/30/12 from 8:50 am to 9:05 am, a storage room door was observed to be propped open and unattended. Five residents were observed to ambulate by the storage room during the time of the observation. Some of the items in the storage room, at approximately three feet from the floor and in plain sight from the hallway were: razors, electric shave lotion, shaving cream, alcohol swabs and instant hot packs.

During an interview on 8/30/12 at 9:07 am, Licensed Practical Nurse (LPN) #1 stated that the storage room door should not have been propped open, that it was supposed to be closed and locked. She also stated that the five residents in the hallway at the time were wanderers and confused and that leaving the door open could have posed a risk for the residents if they had gone into the room and handled the supplies.

During an interview on 8/30/12 at 9:39 am, the DON stated that the storage room door should not have been left open while unattended because this could have been a danger to the residents if they had gone into the room.

Finding 3:
Treatment carts were observed to be unlocked and unattended in the common area hallways on three of three units observed.

The Policy and Procedure (P&P) for Treatments with a review date of 7/1991, documented that carts were to be locked when not in use or unattended, and the treatment nurse was responsible for the treatment cart key.

During observations on 8/39/12 on the A Unit, B Unit and Shaker Place Unit, treatment carts were observed to be unlocked and unattended with residents sitting near and ambulating past the carts. Inventory of the carts revealed items stored in the carts included: hydrocortisone cream, lidocaine cream, muscle rubs, medicated shampoo, and large nail clippers. On the A Unit, it was also observed that keys to the cart were sitting on top of the cart in plain view.

During an interview on 8/30/12 at 9:04 am, LPN#3 stated that the treatment carts were not supposed to be left unlocked and unattended. She stated that the keys were not usually left on top of the cart, and that she did not know who left them there.

During an interview on 8/30/12 at 9:39 am, the DON stated that the treatment carts were not supposed to be left unlocked and unattended because this could have been a danger to the residents if one of them had taken an item from the cart.

10NYCRR 415.12(h)(1)