Bethany Home

Based on observation, resident record review, and staff interview, the facility failed to administer medications in a means that care and medication administration services had been provided according to accepted standards of clinical practice within a locked Memory Care Unit and secondly after a resident had received an ophthalmology procedure and returned to the facility with new orders. The facility reported a census of 67.
Findings include:
1. A continuous observation had taken place on 3/28/23 from 8:14 AM to 8:20 AM.
On 3/28/23 at 8:14 AM the dietary staff entered the Memory Care Unit with the steamer cart server to provide residents breakfast.
On 3/28/23 starting at 8:16 AM, Staff E (RN) had left the area where the medication cart had been and from where medications had been administered by Staff E to residents individually. The medication cart had been left approximately 15 feet from seven Memory Care Residents who had gathered at the round dining room tables. Staff E had been observed leaving the medication cart to enter the unit's kitchenette. Staff E had not been able to view the medication cart. Staff E could be heard opening cupboards in the kitchenette. Again, the medication cart had not been viewed by Staff E. Observed, there had been a clear cup of medications that had been removed from a medication punch card. The cup had been observed to contain approximately seven to eight oral medications. One of the medications had appeared to be one-half a tablet.
At 8:19 AM Staff E returned from the kitchenette to the medication cart. Staff E had then put the clear medication cup of oral medications in a drawer of the med cart. Staff E then exited outside of the locked unit for a couple minutes.
On 03/28/23 at 8:30 AM Staff E was asked who the medications were for that had been on top of the medication cart, and Staff E hesitated to answer then stated the residents name and stated that the observation could not have been seen from over there. Staff E then pointed to an area across the room. During the continuous observation, the position of the surveyor had changed while Staff E was in the kitchenette. Staff E further verbalized fear of the incident being documented and again stated the observation could not have been seen from the surveyor.
2. On 3/29/23 review of Resident #8 Physician Orders had shown that Resident #8 received ophthalmology care on 3/23/23 for the left eye and had been discharged with a change in medication orders. Resident #8 had new orders to discontinue Refresh Celluvisc gel one-percent eye drops administered to the left eye for 3/23/23 and for 3/24/23. Administration to the right eye remained unchanged.
On 3/29/23 Review of the Electronic Medication Administration Record (EMAR) had shown Resident #8 had been administered Refresh Celluvisc one-percent eye drop, instill one drop in both eyes six times a day for dry eyes on 3/23/23 and 3/24/23.
03/29/23 at 10:30 AM an interview completed with Staff F (LPN) who identified a signature on the EMAR for administration of Resident #8 Refresh Celluvisc 1% eye drop, instill one drop in both eyes six times a day for 3/24/23 at 7:00 AM. When asked if the eye drops had been administered to both eyes on that date and time Staff F stated having signed out the medication, then yes the administration would have been to both eyes. Staff F stated Resident #8 had been knowledgeable about ongoing ophthalmic procedures and after care however if the EMAR indicated both eyes then Yes, both eyes would have been administered. Staff F then reviewed the paper document provided by the Ophthalmology clinic that had stated to hold the left eye Refresh Celluvisc gel eye drops for 3/23 and 3/24/23.
On 3/29/23 at 12:10 PM and interview had been completed with Staff G (RN) and Staff H (RN). Both Staff G and H were asked about expectations of staff who passed medications and the situation of when medications had been punched out and put in a medication cup to administer however the staff had to leave the immediate medication area and what would the expectation be for staff concerning the medication. Staff G stated the nurse would have been expected to put another medication cup over the cup containing the medications and then the cup should have been placed in a locked drawer in a locked medication cart. Staff H stated the medications couldn't have been left unsupervised and would need to have been put in a locked med cart and the computer screen would need to be closed. During the interview the process of medication orders had been discussed, review of Resident #8 EMAR had taken place. Both Staff G and Staff H were unaware of the hold for 2 days on the left eye drops, Refresh Celluvisc, and acknowledged staff asked for clarification of the new order for antibiotic eye drops only.
On 3/29/23 a review of the facility policy titled, Medication Administration Policy, listed in the first paragraph that medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician, and in accordance with professional standards of practice. The Medication Administration Policy further stated guidelines listed as Number 1 through Number 22. Statement number 22 stated:
If a nurse or C.M.A. must leave medications prior to administration, label medication cup, cover with an empty medication cup, and place in a locked medication cart until able to return.

Based on observation, interview, and policy review the facility failed to have dietary male staff wear beard restraints, according to the current standards of practice per the Food Code of the FDA (Food and Drug Administration), food service staff must wear hair restraints (e.g., hairnet, and/or beard restraint) to prevent hair from contacting food while they were working in the kitchen to prevent hair from contacting food while cooking, preparing and assembling food for all facility residents. The facility reported a census of 67 residents.
Findings include:
On 3/27/23 at 9:28 AM, an initial tour of the kitchen was conducted with the Dietary Manager. During observations the Dietary Manager introduced a male cook, Staff A, who wore a hairnet and facial mask however no beard restraint. Staff A had visible beard hair on left and right side of their face exposed.
Further observation revealed on 3/27/23 at 9:30 AM that Staff B (dietary aide) who wore a hairnet and facial mask however no beard restraint, assembling food for resident consumption. Staff B had beard hair on the left and right side of his face exposed. Staff C (dietary aide) was also observed with a hairnet and facial mask in place however lacked a beard restraint. Staff C had beard hair on the left and right side of his face exposed. Staff C had been observed in the resident food prep area of the kitchen.
During an observation on 3/28/23 at 9:57 AM, Staff D (dietary aide) observed with a hairnet and facial mask in place however lacked a beard restraint. Staff D had beard hair on the left and right side of his face exposed. Staff D had been observed preparing food in the kitchen at the time of observation.
During an observation on 3/28/23 at 11:50 AM, Staff D did not have a beard restraint on while in the kitchen and preparing facility resident food.
During an interview on 3/28/23 at 2:10 PM, asked the Dietary Manager about the policy of hairnets and beard restraints. When asked if male staff with beards should wear a beard restraint the Dietary Manager stated having never really thought about it. The Dietary Manager had asked, should they? Again, the Dietary Manager had been asked what was the expectations for the male staff with beards and again the Dietary Manager stated being unsure. The Dietary Manager stated the belief that facial masks covered enough of the face. The Dietary Manager stated the facility had beard restraints in the kitchen inventory. The Dietary Manager had been asked if the facility had a policy for hairnets and beard restraints and again stated not knowing as employment began in October of 2022 and not all of the policies had been reviewed by the manager. The Dietary Manager was asked to provide a facility policy for Hair Nets and [NAME] restraints.
During an observation on 3/29/23 at 6:50 AM Staff A and Staff B were observed in the kitchen preparing residents breakfast with a hairnet and facial mask in place however no beard restraints.
On 3/29/23 at 11:30 AM the Dietary Manager was asked again for a facility policy about staff wearing hairnets, beard restraints, the Dietary Manager stated Administration had been going to gather the facility policy.
The facility provided an undated policy titled Dietary Staff Uniform and it directed staff to utilize a hair net which covers the entire head of hair and/or beard must be worn.