Memphis Jewish Home

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to follow physician's orders for the use of oxygen for 1 of 2 (Resident #182) sampled residents reviewed for respiratory care.

Inspectors wroteBased on review of Diclofenac Sodium Topical (where medication is applied directly to a specific surface of the body) Gel 1% (a medication applied to the skin used to treat arthritis pain) packing insert user guide, Federal Drug Administration website, policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 9 (Registered Nurse (RN) B) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 2 errors were observed out of 27 opportunities, resulting in a medication error rate of 7.41%.

Inspectors wroteBased on policy review, the Centers of Disease Control Guideline for Disinfection and Sterilization in Healthcare Facilities review, Centers for Disease Control and Prevention Enhanced Barrier Precautions sign, medical record review, observation, and interview, the facility failed to ensure proper infection control practices were followed when 4 of 11 staff (Licensed Practical Nurse (LPN) A and I, Treatment Nurse J, and Certified Nursing Assistant (CNA) K) failed to wear Personal Protective Equipment (PPE) for Transmission Based (Isolation) Precautions (TBP) and Enhanced Barrier Precautions, failed to follow infection control standards for the use of reusable equipment, and failed to perform hand hygiene for 4 of 14 (Resident #6, #116, #175, and #179) sampled residents.

Inspectors wroteBased on the Level 1 Pre-admission Screening and Resident Review (PASRR) form, medical record review, and interview, the facility failed to resubmit a PASRR after a resident had a new mental health diagnosis and new antipsychotic medication for 1 of 1 sampled resident (Resident #70) reviewed for PASRRs.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure the environment was free of accident hazards when unattended and unsecured sharps were observed in 1 of 119 (room [ROOM NUMBER]) occupied resident bathrooms.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to have a physician's order for the use of an indwelling urinary catheter (a tube inserted into the bladder that drains urine) for 1 of 3 (Resident #57) residents reviewed for the use of an indwelling catheter.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 1 of 15 (300 Hall Medication Cart) medication storage areas was observed unlocked and unsecured and when 1 of 4 staff (Licensed Practical Nurse (LPN A) left medications unsecured and unattended on top of a medication cart.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when multi-use blood glucose meters were not cleaned and disinfected to prevent cross-contamination of bloodborne pathogens for 5 of 5 sampled residents (Resident #65, #74, #88, #277, and #376) reviewed for blood glucose monitoring, 6 of 9 nurses (Licensed Practical Nurse (LPN) #1, #2, #4, #5, #6 and Unit Manager #2) failed to perform hand hygiene, failed to place barriers when performing accucheck monitoring, failed to dispose of contaminated sharps and glucose strips in the sharp container, and administered contaminated pills to 8 of 11 sampled residents (Resident #65, #74, #82, #88, #226, #227, #232, and #376) observed during medication administration. [...]

Inspectors wroteBased on policy review, observation, and interview, the facility failed to promote care that maintained residents' dignity, respect, and quality of care when staff failed to provide and utilize indwelling urinary catheter privacy bags for 3 of 5 sampled residents (Resident # 66, #73, and #377) reviewed for indwelling urinary catheters.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 4 of 9 staff members (Licensed Practical Nurse (LPN) #2, #3, and #4, and Unit Manager #2) left medication carts unlocked, unattended, and out of sight and left medications out of sight and unattended, and when 2 of 16 medication storage areas (200 Hall Low Medication Cart and 400 Hall Low Medication Cart) had internal and external medications stored together.

Inspectors wroteBased on policy review, observation, and interview the facility failed to ensure food was served under sanitary conditions when 3 of 17 staff members (Pantry Aide #1, Sous Chef (the second in command in a kitchen) #1 and Certified Nursing Assistant (CNA) #1) failed to sanitize a thermometer and failed to perform proper hand hygiene during meal service. This had the potential to affect 31 residents who received supper trays on the 100 Hall. The facility had a census of 131 with 126 residents receiving supper trays.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to have discharge and transfer documentation for 1 of 3 sampled residents (Resident #20) reviewed for hospitalization.

Inspectors wroteBased on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete required quarterly Minimum Data Set (MDS) assessments for 2 of 33 sampled residents (Resident #7 and #8) reviewed.

Inspectors wroteBased on medical record review and interview, the facility failed to accurately assess residents for antipsychotic medications for 1 of 33 sampled residents (Resident #21) reviewed.