cms_AK: 51
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 51 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2019-04-24 | 880 | F | 0 | 1 | FNNN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the infection control and prevention program included: 1) a timely facility infection control risk assessment, for use in conjunction with the annual review of the facility-wide assessment, to complete an accurate Facility Assessment; 2) the tracking/trending of employee illness; and 3) required elements of the Water Management Program to prevent the growth and spread of Legionella. These failed practices increased the risk of an insufficient Infection Control Program and increased the potential risk for development and transmission of disease and/or infection in all residents (based on a census of 12). Findings: Facility Infection Control Risk Hazards Assessment Review of the Facility Assessment Tool, updated 3/7/19, revealed: We model our infection control and prevention practices to the current CDC (Centers for Disease Control) guidelines and conduct quality monitoring to evaluate practice effectiveness in our facility. Review of the CDC guidelines Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 3/15/17, revealed: Performance Monitoring and Feedback: Monitor adherence to infection prevention practices and infection control requirements. During an interview on 4/17/19 at 2:50 pm, the Infection Prevention & Control Registered Nurse (IPCRN) stated a facility infection control risk assessment had not been completed in over a year. He/she stated this was late in getting done. During a second interview on 4/19/19 at 12:40 pm, the IPCRN confirmed the last facility infection control risk assessment was completed in (YEAR)-2017. Review of the most current (Wrangell Medical Center) Infection Control Risk Assessment Tool: Environmental Risks revealed it was dated (YEAR)-17. Review of the facility's policy Infection Prevention and Control Program: SEARHC (Southeast Alaska Regional Health Consortium) Wrangell Medical Center Long Term Care, approved 2/26/19, revealed: SEARHC Wrangell Medical Center Long Term Care maintains an organized, effective facility-wide program designed to systematically identify and reduce the risk of acquiring and transmitting infections among residents, visitors, healthcare workers. Employee Illness Tracking During an interview on 4/17/19 at 2:50 pm, the IPCRN stated he/she did not track/trend employee illness/infection. He/she stated this information had never been provided to him/her. Review of the facility's policy Infection Prevention and Control Program: SEARHC Wrangell Medical Center Long Term Care, approved 2/26/19, revealed: In collaboration with the DON (Director of Nursing) and the facility Medical Director the infection preventionist has the authority to institute emergency medical and or administrative action when there is danger or threat to residents and/or personnel regarding infection prevention/control matters. This includes .Collaborate with the Medical Director and Administration to restrict, from job duties, any healthcare personnel, with communicable disease or infected [MEDICAL CONDITION] of job duties have potential to transmit disease. Water Management Program (Legionella Program) During an interview on 4/17/19 at 2:50 pm, the IPCRN stated there was no information he/she could provide on the Water Management Program to prevent the growth and spread of Legionella other than the policy. He/she stated the facility's water had been tested recently, however could not state where the water was sourced from within the facility or if there was more than once source tested . During an interview on 4/19/19 at 12:43 pm, the IPCRN stated that he/she did not know if the facility's Water Management Program included the creation of a diagram of the building water system or if areas where legionella could grow and spread were identified based on this diagram. He/she could not provide any control measures that would have resulted from this procedure of the program. He/she stated maintenance would have been involved with the mapping and diagraming of the facility's water system. During an interview on 4/19/19 at 1:03 pm, the Facility Manager stated maintenance did not participate in any mapping or diagraming of the facility water system. Review of the facility's Water Management Policy, revised 3/2018, revealed the following procedures: 1. Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens .would grow and spread in the facility water system. 2. Implement a water management program that considers the ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) industry standard and the CDC toolkit, and includes control measures . Review of the Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings CDC Toolkit (which used the ASHRAE 188: [DIAGNOSES REDACTED]: Risk Management for Building Water Systems, dated 6/26/2015, as reference), dated 6/5/17, revealed: Elements of a Water Management Program: 1. Establish a water management program team; 2. Describe the building water systems using text and flow diagrams; 3. Identify areas where Legionella could grow and spread; 4. Decide where control measures should be applied and how to monitor them; 5. Establish ways to intervene when control limits are not met; 6. Make sure the program is running as designed and effective; 7. Document and communicate all activities. | 2020-09-01 |