Marlette Community Hospital Ltcu

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was properly labeled, dated and stored to maintain best practices resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.

Inspectors wroteBased on interview and record review the facility failed to maintain a comprehensive infection control program, resulting in the facility not mapping infections or completing audits and the potential for infection clusters to go unnoticed.

Inspectors wroteBased on interview and record review, the facility failed to evaluate and document the clinical rationale for the continuation of a PRN (as needed) anti-anxiety medication beyond 14 days and failed to identify a stop date of the medication for one resident (R6) of five residents reviewed for unnecessary psychotropic medication use, resulting in potential for overuse of the medication.

Inspectors wroteBased on interview and record review the facility failed to develop a baseline care plan for one resident (R25) of two reviewed, resulting in the lack of a baseline care plan for oxygen administration.

Inspectors wroteBased on observation, interview and record review the facility failed to provide routine dental services for one resident (R15) of one reviewed for dental services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to date mark potentially hazardous foods, maintain sanitary equipment, and maintain proper glove use and handwashing, resulting in an increased risk of foodborne illness, affecting all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% based on five medication errors of 34 medication administration opportunities. This deficient practice resulted in a medication error rate of 14.7%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store and dispose of medications and ensure insulin pens and eye drops were labeled with dates when opened in two medication carts of two medication carts reviewed for medication storage and labeling.

Inspectors wroteBased on interview and record review, the facility failed to implement tracking of Covid-19 (a highly contagious respiratory disease) immunizations to ensure appropriate education was offered and vaccinations administered or declined for four residents (R13, R17, R30 and R35) of five residents reviewed for immunization, resulting in the potential for residents and resident representatives to be uninformed of the benefits and potential side effects of Covid-19 vaccination and the potential for eligible residents to remain unvaccinated, increasing the risk of disease.

Inspectors wroteBased on observation, interview and record review, the facility failed to appropriately monitor for a change in condition per professional standards of practice for one resident (Resident #30) of one resident reviewed for hospitalizations, resulting in the potential for delayed treatment and a further deterioration of condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and assistance to wear and be able to use a prosthetic device for one resident (Resident #20) of one resident reviewed for activities of daily living with a prosthesis.

Inspectors wroteBased on interview and record review, the facility failed to ensure that 27 out of 27 residents received their mail on Saturdays, resulting in residents not being able to exercise their right to receive mail and access communication. Findings Include: On 7/20/23 at 1:30 PM, during a meeting with a Confidential Group of Residents, they were asked if they received mail on Saturdays. The group replied, No, we don't. With further discussion, the residents said it was something they had recently been talking about, because they were not receiving their mail on Saturdays. During an interview with the Activities Director F, on 7/20/2023 at 2:30 PM, she was asked if the resident's received mail on Saturdays and she said they did not. She said the mail was handled through the storeroom in the hospital. [...]

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to ensure appropriate medication practices including appropriate removal of narcotics from the medication dispensing system and Failed to ensure that the medication refrigerator freezer in the Medication Room was defrosted routinely and to obtain routine temperatures of the medication room refrigerator to ensure medications remained at an appropriate temperature to retain efficacy, potentially effecting all 27 residents in the facility. Findings Include: FACILITY Medication Storage and Labeling On 7/21/23 at 9:04 AM, during a review of the medication storage room with the Director of Nursing/DON, a yellow sticky note was observed stuck to the front of the medication dispense system in the med room. The sticky note had multiple crossed off months and years ending with July 2023. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Properly label and date food and food products, 2. Dispose of expired food and food products, 3. Ensure chemical cleaning agents were maintained separate from food, 3. Ensure use of a beard restraint by kitchen staff, 4. Ensure cold food items were stored at 41 degrees Fahrenheit or less, 5. Ensure dry food products were stored in a manner to prevent contamination, 6. Institute monitoring of chemical dishwasher processes to ensure staff understanding and correct chemical sanitization dishwasher temperature and chemical levels, and 7. Maintain sanitary conditions in the kitchen, resulting in the increased potential for cross-contamination and foodborne illness. These deficient practices had the potential to affect 27 residents who receive food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to review and revise care plans with resident changes, to ensure interventions necessary for care and services were provided for 4 resident (Resident #10, Resident #19, Resident #21, Resident #28) of 27 resident reviewed, resulting in the potential for unmet care needs. Findings Include. Resident #10: Position, Mobility On [DATE] at 12:30 PM Resident #10 was observed sitting in a wheelchair in her room and appeared to be sleeping. A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated the resident was admitted to the facility on 7/13 2018 with diagnoses: Alzheimer's Disease, heart disease, Rheumatoid arthritis, spinal stenosis, GERD, depression, history of skin cancer, hypothyroidism, hypertension and weakness. New diagnoses: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement policies and procedures for use, assessment, and ongoing evaluation of bed rail use for five residents (Resident #7, Resident #12, Resident #14, Resident #17, Resident #129) of five residents reviewed resulting in lack of identification and implementation of alterative interventions, lack of entrapment assessment documentation, maintenance and monitoring of side rails, extremely loose and moveable rails, and the likelihood for injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure that advance directive documentation was meticulously completed and the policy/procedure implemented for one resident (Resident #129) of one resident reviewed resulting in incomplete Do Not Resuscitate (DNR) documentation and the potential for the resident's wishes to not be followed and unwanted and/or undesired medical care/treatment in a medical emergency.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that Restorative Nursing services were provided to 1 resident (Resident #10) of 3 residents reviewed for range of motion and restorative services from a total sample of 27 residents, resulting in Resident #10 developing lower extremity contractures and the decreased ability to ambulate. Findings Include: Resident #10: Position, Mobility On 7/19/2023 at 12:30 PM Resident #10 was observed sitting in a wheelchair in her room and appeared to be sleeping. A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated the resident was admitted to the facility on 7/13 2018 with diagnoses: Alzheimer's Disease, heart disease, Rheumatoid arthritis, spinal stenosis, GERD, depression, history of skin cancer, hypothyroidism, hypertension and weakness. New diagnoses: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate less than 5% when two medication errors were observed for two residents (Resident #80 and Resident #129) from a total of 29 observations, resulting in a medication error rate of 6.9%. This deficient practice resulted in the potential for adverse medication effects and decreased medication efficacy related to lack of implementation of standards of practice for medication administration and incorrect administration dosage.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow evidence-based practices for Infection Control, including collection and analysis of surveillance data to identify trends and patterns and implement appropriate interventions, and to follow the interventions initiated. The failure to maintain infection control practices resulted in the potential for a serious adverse outcome including infectious illness and death if appropriate Infection Prevention and Control Standards of Practice were not enacted. Findings Include: Infection Control: On 7/19/2023 at 1:05 PM, the Director of Nursing/DON was interviewed related to a Personal Protection Equipment/PPE cart outside Resident #20's room door. The DON was asked what type of precautions were in place and she said she wasn't sure. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Infection Preventionist had completed the required training in Infection Prevention and Control. This deficient practice resulted in the potential for a lack of knowledge and appropriate response to aid in the prevention of infections that could lead to resident illness, outbreaks and possibly death. Findings Include: FACILITY Infection Control: On 7/21/23 at 4:09 PM, the Infection Control task was reviewed with Infection Prevention and Control Nurse T and the Director of Nursing/DON. The IPC said she worked as the IPC at the facility from February 2023 until June 2023 with the DON's assistance. The DON said she is trying to hire someone for the role and is currently performing the IPC role. Neither IPC T or the DON have IPC training. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignified and respectful verbal communication about and with one resident (Resident #129) of one resident reviewed resulting in a staff member speaking about the Resident in a disrespectful manner at the nurses' station within audible range of the other residents, family, and staff, and a staff member telling the resident they had to leave the facility, and resident verbalization of anxiety and distress.