Emergency Preparedness Deficiency in Water and Medication Supply
Penalty
Summary
The facility was cited for failing to ensure that subsistence needs for residents and staff were maintained during an emergency. The Emergency Preparedness Plan, last updated by the previous Administrator, accounted for 1 gallon of water per resident per day for three days, totaling 240 gallons, but did not include provisions for staff or visitors. Additionally, the facility did not have an emergency supply of temperature-dependent medications. Observations revealed that medication room refrigerators on both the first and second floors were plugged into regular outlets, not supported by the emergency generator. Interviews with the LPN and the Administrator confirmed the lack of emergency cold medication supplies and the oversight regarding the generator support for medication refrigerators. The Director of Environmental Services stated that the generator supported other critical systems but not the medication refrigerators.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 Loss of Food Service Policy has been revised to reflect that additional water will be on hand to account for staff and others, including volunteers or unexpected visitors. All Department Managers received education on the updated Emergency Preparedness Plan as pertains to the water supply on hand and that emergency medication refrigerators need to be on generator outlet. The refrigerator on the second-floor medication room was placed on a generator outlet for use for temperature dependent medication supply during an emergency. Will review the Loss of Water and Loss of Food Supply as part of the Emergency Preparedness Plan Quarterly. Will Review any updates with Quality Assurance and Performance Improvement Committee Quarterly for 1 year to ensure compliance. Person Responsible For Completion: Director of Environmental Services