Unauthorized and Unlabeled Items Found in Medication Room Refrigerator
Penalty
Summary
Surveyors observed that the Sub-Acute unit medication room refrigerator contained unauthorized and unlabeled items, including a can of Coca-Cola, a pint-sized Oatmeal Extra Thick, and an eight-ounce Ensure, none of which were labeled with a name or date. Additionally, a Licensed Vocational Nurse (LVN) was seen retrieving a bag of food from the medication room and admitted to storing personal food there due to previous incidents of food loss in the employee refrigerator. The LVN acknowledged that staff are not permitted to place their food in the resident-designated refrigerator. The facility administrator confirmed the presence of the unauthorized and unlabeled items in the medication room refrigerator and stated that only properly labeled resident food, with name and date, is allowed in that refrigerator for up to three days. The facility's infection prevention and control policy requires maintaining a safe, sanitary environment to prevent the transmission of diseases and infections, which was not followed in this instance.
Plan Of Correction
F 880 Infection Prevention & Control How corrective actions will be accomplished for these residents found to have been affected by the deficient practice: On 4/4/25, RN Supervisor immediately removed the Coca-Cola can, one pint sized Oatmeal Extra Thick, one eight ounce ensure, and bag of food from LVN 1 from the Sub-Acute medication room refrigerator designated for resident food. On 4/4/25, RN Supervisor immediately conducted a 1:1 education for LVN 1 regarding "No Employee Food in Resident's Refrigerator." How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/4/25, RN Supervisor made observed SNF Medication Room Resident food refrigerator to identify if the same deficient practice occurred. No deficient practice identified and was reported to the Administrator. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: Beginning 4/4/25, RN Supervisor(s) provided in-service to licensed nurses and CNAs regarding resident food refrigerator use and no employee food should be placed in resident food refrigerator. In-services regarding resident food refrigerator and no employee food refrigerator completed on 4/25/25. On 4/25/25, Administrator revised "Form A of Policy No. - DS 53, Refrigerator / Freezer Temperature Log" to include DAILY checking of RESIDENT ONLY FOOD STORED IN REFRIGERATOR to be completed by licensed nurses. If deficient practice is identified, it will be corrected immediately. How the facility plans to monitor its F 880 performance to make sure that solutions are sustained: ICP will review revised Form A of Policy DS - 53 - Refrigerator / Freezer Temperature Log" monthly and report findings to the DON and/or Administrator. Findings will be brought to the attention of the QAPI Committee monthly x 3 months for further recommendations.