SEDGWICK COUNTY MEMORIAL NURSING HOME

A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). This survey was conducted on January 4, 2024 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."This structure is a one (1) story, Type V (000) construction. This original facility was constructed in 1961. The facility is licensed for 32 beds and the census on the date of the survey was 28. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe fire sprinkler system. This facility is classified as fully sprinklered. The results of this survey were discussed with the Administrator and the Maintenance Director during the exit conference.

Based on observation during the course of the survey it was determined the facility failed to maintain a hazardous area in accordance with NFPA 101, Section 19.3.2.4 and NFPA 99. This was evidenced by the following:1. Soiled utility room in Northeast hall door does not latch closed. NFPA 101, 21.3.2.1 Doors. Doors to hazardous areas shall be self-closing or automatic closing in accordance with 21.2.2.4. This deficiency has the potential to affect all occupants and staff within the smoke compartment. This deficiency was discussed during the survey and again during the exit conference.

Based on record review it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96, (Chapter 11, Section 11.6.2 and 11.7.1)This was evidence by the following:1. No current records or documentation for kitchen hood cleaning. NFPA 96, 11.6.2* Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to remove combustible contaminants prior to surfaces becoming heavily contaminated with grease or oily sludge. NFPA 96, 11.7.1 Inspection and servicing of the cooking equipment shall be made at least annually by properly trained and qualified persons. This deficient practice could affect all residents, and staff should a fire occur. This deficiency was discussed during the exit conference.

Based record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the NFPA 101, Life Safety Code Section 19.3.4.1 and NFPA 72. This was evidenced by:1. No records or documentation for 2-year smoke detector sensitivity testing. NFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72, 14.2.1.1.2 Inspection, testing, and maintenance programs shall verify correct operation of the system. NFPA 72, 14.4.5.3* In other than one- and two-family dwellings, sensitivity of smoke detectors and single- and multiple-station smoke alarms shall be tested in accordance with 14.4.5.3.1 through 14.4.5.3.7. NFPA 72, 14.4.5.3.1 Sensitivity shall be checked within 1 year after installation. NFPA 72, 14.4.5.3.2 Sensitivity shall be checked every alternate year. This deficiency was discussed during the exit conference.

Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25,5.3.1.1.1 and NFPA 101, 19.7.6, and 4.6.12. This was evidence by the following. 1. Missing quarterly fire sprinkler inspection reports. NFPA 101 Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. Section 19.7.6, 4.6.12, and NFPA 25, 5.2.1 This deficiency could affect all residents, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. This was discussed during the exit conference.

Based on observation it was determined that the facility failed to maintain all portable fire extinguishers as required by NFPA 10 Chapter 4 and LSC 101, 9.7.4. This was evidence by the following. 1. No records or documentation of fire extinguisher locations listed on annual inspection report. NFPA 101, 9.7.4. Where required by the provision of another section of this code, portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10 Standards for Portable Fire Extinguishers. NFPA 10, 7.2.1.1 Fire extinguishers shall be manually inspected when initially placed in service. NFPA 10, 7.2.4.3 Where at least monthly manual inspections are con-ducted, the date the manual inspection was performed and the initials of the person performing the inspection shall be recorded. This deficient practice could affect all residents, staff and visitors should the portable fire extinguisher be needed in the event of fire. The Maintenance Director acknowledged the deficiency during record review. This deficiency was discussed during the exit conference.

Based on observation, it was determined that the facility failed to maintain proper electrical practices in accordance with NFPA 101, 9.1.2, and NFPA 70, National Electrical Code Section 110.12. This was evidenced by the following deficiencies:1. Ceiling fixture in Northeast hall has exposed wiring. NFPA 101, Section 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical CodeNFPA 70, Section 110.12 Electrical equipment shall be installed in a neat and workmanlike manner. This deficient practice could affect all occupants and staff throughout the smoke compartment if improper maintenance of electrical equipment causes a fire. The deficiency was discussed during the exit conference.

A recertification survey with complaint #CO33773 was conducted on 12/11/23 to 12/13/23. Two deficiencies were cited.

An Emergency Preparedness survey was conducted from 12/11/23 to 12/13/23. No deficiencies were cited.

Based on observations and interviews, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the possible development and transmission of Coronavirus (COVID-19) on one of one unit. Specifically, the facility failed to:-Ensure staff wore and removed personal protective equipment (PPE) correctly; and,-Ensure infection control practices were followed during medication pass. Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC), revised 5/8/23, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During Coronavirus Disease 2019, retrieved 12/18/23 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html"Source control options for HCP (healthcare personnel) include a NIOSH (National Institute for Occupational Safety and Health) approved particulate respirator with N95 filter or higher. Source control is recommended for individuals in healthcare settings who: Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with SARS-CoV-2 infection, for 10 days after their exposure. Source control is recommended more broadly as described in CDC's Core IPC Practices in the following circumstances: By those residing or working on a unit or area of the facility experiencing a SARS-CoV-2 or other outbreak of respiratory infection; universal use of source control could be discontinued as a mitigation measure once the outbreak is over ( no new cases of SARS-CoV-2 infection have been identified for 14 days); Eye protection (goggles or a face shield that covers the front and sides of the face) worn during all patient care encounters."I. Facility policy The Infection Control policy, issued 5/1/21, was received from the director of nursing (DON) on 12/13/23 at 12:18 p.m. The policy documented in pertinent part, "This facility has established and maintains 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. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies."II. Failure to ensure staff doffed (removed) and donned (put on) PPE properly for COVID-19 isolation roomsA. Observations The two Covid-19 isolation rooms were observed on 12/11/23 at 9:56 a.m. Two isolation carts were noted in front of resident rooms and both of the rooms had clear plastic zippered material covering the doorways. At 9:57 a.m. certified nurse aide (CNA) #1 and CNA #2 prepared to enter the room. CNA #1 put on a yellow cloth gown and gloves and entered the room. She was wearing the same surgical mask she had been wearing previously. CNA #2 removed her surgical mask and set it on the table outside of the room. She put on a yellow cloth gown, gloves and a new surgical mask and entered the room with CNA #1. Both CNA #1 and CNA #2 assisted the isolated resident with toileting. At 10:08 a.m., CNA #1 and CNA #2 exited the room. They both had removed their yellow cloth gowns in the room. Upon exiting the room, the CNAs rolled up the gowns and put them back in the storage bin outside of the room. They removed and disposed of their gloves in the room. CNA #1 asked CNA #2 if they were reusing the yellow gowns and CNA #2 responded that they were and that is why they put them back in the storage bin. CNA #1 left the area. CNA #2 disposed of the surgical mask that she was wearing inside the room and put on the original surgical mask that she had left on the table outside of the room. On 12/12/23 at 2:39 p.m., licensed practical nurse (LPN) #1 was observed sitting at the nursing station. She had a surgical mask under her chin. It was not covering her nose or mouth. On 12/12/23 at 2:41 p.m., LPN #1 was observed sitting at the nursing station. She had a surgical mask under her chin. It was not covering her nose or mouth. On 12/13/23 at 9:37 a.m., LPN #1 was observed sitting at the nursing station. She had a surgical mask under her chin. It was not covering her nose or mouth. B. InterviewsCNA #2 was interviewed on 12/11/23 at 10:10 a.m. She said there were two rooms on isolation precautions for positive Covid-19 tests. She said the room she just exited would be coming off of isolation in the next couple of days. She said all staff should be wearing N95 masks but since the isolation was almost over she did not think it was important. She said the CNA's had to reuse the isolation gowns and that was why she put her gown back in the container after she exited the room. The DON was interviewed on 12/11/23 at 10:50 a.m. She said Covid-19 positive residents were placed on a ten day isolation. She said the correct process for entering an isolation room was to perform hand hygiene, don a gown, gloves and N95 mask. Upon exiting the room, she said all of the PPE should be removed in the room and put into a red biohazard bag before exiting. Once staff was outside of the room the red bag should be placed in a specific trash can and the staff should perform hand hygiene again. She said it was not appropriate to wear a surgical mask when providing care inside an isolation room or to reuse the gowns. She said she would re-educate staff on the proper technique for PPE. The DON was interviewed again on 12/13/23 at 9:56 a.m. She said all of the staff had been told they were required to wear a surgical mask covering their nose and mouth unless they were in the break room to eat. She said it was important for staff to follow proper mask procedures to avoid contamination and spread of the Covid-19 virus. Licensed practical nurse LPN #1 was interviewed on 12/13/23 at 10:04 a.m. She said she was aware of the mask mandate for the facility that was currently being required due to the Covid-19 outbreak. She said all staff and visitors were to wear masks covering their nose and mouths at all times. She said masks should be worn properly even if the nurse was sitting at the nurses station. III. Failure to follow infection control practices during medication passA. ObservationsLicensed practical nurse (LPN) #1 was observed on 12/12/23 at 11:54 a.m. during medication administration. She had just returned from a meeting with the DON when she approached the cart and began preparing medications for a resident. -She did not sanitize her hands prior to getting a medication cup and dropping the medications in it. LPN #1 carried the medication cup to the resident in the dining room and the resident put the cup to her lips to take the medications. LPN #1 took the medication cup back from the resident and threw it away in the trash can. She returned to the medication cart and got another medication cup to begin preparing the medication for the next resident. -She did not sanitize her hands prior to preparing the next resident's medications.. She carried the medication cup to the resident in the dining room and the resident put the medication cup to her lips to take the medication. LPN #1 took the medication cup back from the resident and threw it in the trash. At 11:58 a.m., LPN #1 took the medication cup back from a resident in the dining room and threw it in the trash. She proceeded to touch a handheld radio, scratch her head, use the computer mouse and unlock the medicine cart with her keys. She then got a medication cup and began putting the medications in the cup for the next resident. -She did not sanitize her hands prior to preparing the next resident' s medications.. At 12:00 p.m., LPN #1 administered medications mixed with applesauce toa resident in the dining room. She used a spoon to administer the medications to the resident.. After the resident ingested the medications she threw the medication cup and spoon into the trash can. She returned to the medication cart and unlocked the cart using her keys. She got a medication cup and began dropping the medications into the medication cup for the next resident. -She did not sanitize her hands prior to preparing medications for the next resident. She took the medication cup to the resident who put the medication cup to their lips to take the medications. LPN #1 took the cup back from the resident and threw it in the trash. -Without sanitizing her hands, LPN #1 then got another resident a cup of coffee from the kitchen and gave it to the resident. At 12:07 p.m., LPN #1 prepared and administered medications in a medication cup to another resident in the dining room. She threw the medication cup in the trash and returned to the medication cart. She got a new medication cup from the cart and began preparing medications for the next resident. She put the medications in the medication cup with some applesauce, took it to the resident and administered it. She then threw the medication cup and spoon in the trash and returned to the medication cart. -She did not sanitize her hands prior to preparing the medications for the next resident. At 12:16 p.m., LPN #1 began preparing medications for the next resident. An alarm began sounding at the nurses station so she walked to the nurses station and pushed a button to cancel the alarm. She returned to the medication cart and placed a medication cup on top. The alarm began sounding again so she returned to the nurses station and pushed the button again to cancel the alarm. She returned to the medication cart and continued to prepare the medications for the next resident in the dining room. -She did not sanitize her hands after touching the button on the alarm at the nurses station.. She carried the medication cup to the resident in the dining room and the resident placed the cup to their lips to take the medications. LPN #1 took the medication cup back and threw it in the trash.-She did not sanitize her hands prior to preparing the next resident's medications. At 12:20 p.m., LPN #1 delivered a medication cup to a resident in the dining room. The resident placed the medication cup to his lips to take the medication. LPN #1 took the medication cup back and threw it in the trash. She walked back to the medication cart, got a medication cup and placed it on top of the cart. She unlocked the medication cart with her keys and began preparing the medication for the next resident. -She did not sanitize her hands prior to preparing the next resident's medications.. She carried the medication cup to the resident and he refused to take the medication. LPN #1 returned to the medication cart and put the medication in the medication waste container and threw the medication cup away. B. InterviewsThe DON was interviewed on 12/13/23 at 9:56 a.m. She said all staff were expected to wash their hands or use hand sanitizer between each medication pass. She said staff should use hand sanitizer before getting the medications, after taking the medication to the resident and again before starting the next resident. She said it was important to perform hand hygiene to prevent the spread of pathogens from one resident to the next. LPN #1 was interviewed on 12/13/23 at 10:04 a.m. She said nursing staff should use hand sanitizer between each resident during medication administration. She said failure to perform hand hygiene between each resident could result in germs spreading from resident to resident.

Based on observations and interviews, the facility failed to maintain the emergency response cart and equipment in safe operating condition for one of one emergency response (crash) cart. Specifically, the facility failed to:-Ensure staff completed the daily equipment checks;-Ensure expired items were removed from the crash cart; and,-Ensure emergency oxygen canister on the emergency response cart was maintained and ready for use. Findings include:I. Professional referencesA. According to Mortell, Manfred, (2022). "Crash cart preparedness and failure to rescue" a case study review. Retrieved on 12/18/23, from https://www.researchgate.net/publication/360555126_Crash_cart_preparedness_and_Failure_to_rescue_A_case_study_review and read in pertinent part,"A crash cart is a mobile cabinet on wheels that contains equipment required for emergency cardio-pulmonary resuscitation. The carts are individualized and conveniently located throughout healthcare facilities for rapid access in the event of an emergency. "A crash cart is typically located in the setting of an unexpected medical emergency. This could include severe allergic reaction, cardiac or respiratory arrest, and conditions with an unexpected sudden deterioration of vital signs. This would require equipment located on the card cart which would be used by a credentialed life support provider. While crash carts vary depending on location, the fundamentals for the crash cart will contain similar equipment. "Although the organization of requirements for a crash cart is not generic, there is a fundamental standard which provides effortless access to emergency medical equipment. Note that all these organizational points are checked, dated, and signed by the staff member who performed the daily routine inventory and inspection. "Top shelf/drawer-The top section typically has the most frequently used equipment employed in a resuscitation event such as power cords and personal protective equipment."Side or rear-The oxygen cylinder should be secure on the side of the cart, with a full oxygen pressure level;-A suction apparatus/charging battery for the portable use;-A sharps container should be secure on cart; and,-A rigid plastic/fiberglass backboard for chest compressions."Recommended equipment and medications-Organization and location specific."Recommended maintenance-Check expiration dates on equipment and medications per organization policy and replace as required."Schedule inventory check"The purpose of a crash cart inventory is to organize a schedule of when to check for expiration dates of equipment and supplies."Check that equipment is operating as required in the event of an emergency. In addition to recording who performed the inventory checks, with dates, times, and signatures. An alarming situation for the healthcare personnel requiring a crash cart is to find unusable equipment or expired medications in an emergency. Ensuring that an up-to-date, accurate, and truthful inventory record can avoid potential patient safety situations such as absence of equipment, equipment failure, expired or missing medication, and empty oxygen cylinders."The patient safety risk incident failure to rescue is perpetrated by healthcare professionals when they do not check cart accurately. Failure to follow standard or policy for checking equipment compromises patient safety and creates potential to harm patients." II. Facility policyThe Nursing Home Crash Cart policy, issued 12/23, was received from the director of nursing (DON) on 12/13/23 at 12:18 p.m. and read in pertinent part, "The DON will ensure the equipment is stocked in the E-Cart (emergency cart). The DON contacts the materials management clerk for the equipment supplies. The E-Cart will be inventoried and restocked after each use and checked at least monthly and documented by nursing staff. All emergency equipment in the E-Cart will be checked monthly by the DON. Once a month the E-Cart should be opened and checked for outdated supplies. Internal and external equipment should be checked by ensuring proper function of equipment. E-Cart checks should be documented on the lists maintained on the E-Cart. E-Carts will be maintained and supplied in accordance with the crash cart minimum requirements list which include respiratory equipment."III. ObservationsCrash cart #1 was observed on 12/12/23 at 9:02 a.m. The following items were found:-There was not a daily checklist on the cart;-One 100 milliliter (ml) bottle of sterile water, expired on 12/21; -Ambu (manual self-inflating resuscitator) bag, expired in 2013;-Midline catheter, expired on 12/31/2020;-Catheterization tray, expired on 2/13/2020;-Suction tubing, expired on 3/1/21;-Yankauer device (oral suctioning tool), expired on 7/19/17;-Yankauer device, expired on 7/31/23;-Three sets of sterile gloves, all expired in April 2020;-Sterile gloves, expired in August 2020;-Basic oxygen mask, expired on 6/31/23;-Carbon dioxide detector, expired on 7/9/19;-Carbon dioxide detector, expired on 7/11/2020;-Two suction tray kits, both expired on 2/13/2020;-Two boxes of standard gloves, expired in June 2015 and May 2015; and,-The oxygen canister on the cart did not have any oxygen in it. IV. InterviewsThe DON was interviewed on 12/12/23 at 11:39 a.m. The DON said she was responsible for completing the daily checklists for the crash cart. She said she would contact the supply department and have them go over everything on the crash cart and order new supplies. She said she would make sure the oxygen canister was replaced with a full canister immediately. The DON said it was important for the crash cart to be stocked with current ready to use supplies and equipment to be able to effectively resuscitate someone in the event of an emergency. Licensed practical nurse (LPN) #1 was interviewed on 12/13/23 at 10:04 a.m. She said she did not know who was responsible for checking the crash cart or the items on it. She said she was not instructed to do so. She said the crash cart should have all of the supplies required to be able to use if someone had an emergency and needed to be revived.

A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.