Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 01G011 (X3) Date Survey Completed 06/12/2019
Name of Provider or Supplier Rainbow Omega, Inc, Street Address, City, State 202 Hope Drive, Eastaboga, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
W0341 NURSING SERVICES
CFR(s): 483.460(c)(5)(ii)

Nursing services must include implementing with other members of the interdisciplinary team, appropriate protective and preventive health measures that include, but are not limited to control of communicable diseases and infections, including the instruction of other personnel imethods of infection control.


This STANDARD is not met as evidenced by:
The facility failed to conduct medication pass in a manner to ensure infection control techniques were used. The nurse was observed to not clean, nor sanitize the sharp object (ink pen) prior to using it to score the blister pack to take the pills out. This was observed with seven of twelve pills removed from the blister pack. The effected Resident Identifier (RI) #2, RI #5, RI #6, RI #7, RI #8, RI #9 and RI #10, seven of eight residents observed for medication pass.

Findings include:

Review of an undated facility policy titled : " Intermediate Care Facility, Nursing Policy and Procedures Medication Administration .... " Perform the procedures as follows: ... using a sharp object: maneuver around the edge of the foil seal. Once you have torn the foil: remove it completely. Turn bubble pack upside down over medicine cup so that the pill is safely removed into the cup. Another option for removal would be to place the medicine cup behind the bubble and punch the pill into the medicine cup. ..."

During the medication pass on 6/11/19 being at 3:49 PM, EI #1 was observed to use the pen tip to open the back of the blister pack of medication for RI #5. The nurse did not clean nor sanitize the pen prior to use.

During the medication pass at 3:53 PM, EI #1 was observed to use the pen tip to open the back of the blister pack of medication for RI #6. The nurse did not clean nor sanitize the pin prior to use.

After the medication administration for RI #6 , EI #1 was observed to use the pen tip to open the back of the blister pack of medication for RI #7. The nurse did not clean nor sanitize the pen prior to use.

EI #1 continued with the med pass going to RI #8. EI #1 was observed to use the pen tip to open the back of the blister pack of medication to get the pill out. The nurse did not clean nor sanitize the pin prior to use.

During the medication pass on 6/11/19 at 4:04 PM, EI #1 was observed to use the pen tip to open the back of the blister pack to get the pill out for RI #9. The nurse did not clean nor sanitize the pen prior to use.

EI #1 continued her med pass going to RI #2. EI #1 was observed to get the pin out of her pocket and use the pen tip to open the back of the blister pack to get the pill out for RI #2. The nurse did not clean nor sanitize the pen prior to use.

During the medication pass on 6/11/19 at 4:14 PM, EI #1 was observed to use the pin tip to open the back of the blister pack for RI #10. The nurse did not clean nor sanitize the pen prior to use .

In an interview on 6/11/19 at 4:57 PM, with EI # 1, she was asked how were staff supposed to get pills out of the blister packs. EI #1 replied sign the back of the blister pack and then run the pen around the edge of the paper and then peel the paper back. EI #1 was asked should she put the pen in her pocket and then use it on the blister pack. EI #1 replied if you are not touching the pill, she did not guess you should. EI #1 was asked how did the facility teach her how to get the pills out of the blister pack. EI #1 replied that was how the nurse showed her. EI #1 was asked why should she not take the pen out of her pocket and use it. EI #1 replied if she touched the pill it would potentially cross contaminate. EI #1 was asked if there was a potential for the pill to touch the edges where the pen touched the blister pack. EI #1 replied it probably could.

In an interview on 6/12/19 at 3:00 PM, with EI #2, the Registered Nurse, it was asked if staff are to have a sharp object to cut around the film or put the medication over the medication cup and pop the pill through. He answered the nurses here have been trained to cut around the film. When asked where the staff should get the sharp object from. EI #2 replied that was a good question. He added that he would use a pen top. EI #2 was asked if he would clean the pin top first. EI #2 replied yes because it was an infection control issue. EI #2 was asked if staff should put the pen in their pocket and then pull it out and use it to open the blister pack. EI #2 replied it was an infection control issue.