Deficiencies in Equipment Maintenance, Documentation, and Temperature Control
Penalty
Summary
The facility failed to ensure that essential resident care equipment and medication storage areas were maintained in safe operating condition. During an inspection of Medication Cart C, a glucometer was found with quality control records that did not accurately reflect the reference ranges listed on the test strip bottle. The quality control log documented incorrect reference ranges for both normal and high controls, which did not match those on the bottle. The LVN interviewed confirmed that the night shift nurse was responsible for quality control, and acknowledged the discrepancy in documentation. Further review of quality control records for two other glucometers revealed improper correction of documentation errors. Whiteout was used to alter entries on the Quality Control Records for Glucometers A and B, which completely erased the original information and made it impossible to refer back to previous entries. Both the ADON and DON confirmed that the facility's process should involve crossing out errors and initialing corrections, not using whiteout, and acknowledged that the observed practice was incorrect. Additionally, the medication refrigerator in Medication Room A was not maintained within the required temperature range. Multiple temperature checks showed readings above the acceptable limit, with the refrigerator containing various medications including insulin and Epogen. The presence of condensation and wet medication trays was also noted. In the kitchen, the walk-in freezer was observed with ice buildup along the door frame and on storage bins, which was verified by the Food and Nutrition Services Director.