cms_AK: 75

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

Data source: Big Local News · About: big-local-datasette

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rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
75 WRANGELL MEDICAL CENTER LTC 25015 P.O. BOX 1081 WRANGELL AK 99929 2018-04-30 880 F 0 1 O8F911 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation the facility failed to ensure the infection prevention and control committee had reviewed the infection control plan and policies/procedures on an annual basis, developed and implemented a program specific to the facility assessment, and include required infection prevention and control plan elements. In addition a medical device was not maintained in a clean manner for 1 Resident (#10) out of 1 resident reviewed for indwelling urinary catheter. Specifically the facility failed to; 1. Conduct an annual review of its Infection Prevention Control Plan and Infection control policies 2. Identify the criteria used for infection surveillance to identify possible communicable diseases or infections before they can spread to other persons in the facility, identify what infections, when and to whom the infections should be reported to and document antibiotic process, outcome surveillance and action plans 3. Establish and implement a water management program that included policies and procedures, specific for the facility to mitigate the risk of growth and spread of Legionella and other opportunistic water borne pathogens in the facility's water system 4. Prevent an indwelling urinary catheter bag from resting on the floor These failed practices increased the risk for development and transmission of disease and infection and increased the risk of multidrug resistance in a vulnerable population of all residents based on a current census of 10. Findings: 1) Annual Review of Infection Prevention Control Program and Policies Review of the facility's policy Infection Prevention and Control Program with a revision date of 6/2016, revealed the policy had not been reviewed for 22 months. Additionally randomly reviewed infection control policies revealed last reviewed dates of: - Glucometer Cleaning, revision date 3/2016 - Hospital Acquired Infections, revision date 6/15/2016 - Hand Washing, revision date 6/2016 - Universal Precautions, revision date 6/2016 - Exposure Control Plan: [MEDICAL CONDITION], did not have any dates and appeared to be a draft form During an interview on 4/26/18 at 1:02 pm, the Infection Control Preventionist (ICP) stated the Infection Control Committee was behind on reviewing infection control policies and procedures. 2) Infection Prevention and Control Plan Policy Elements Review of the facility's Infection Prevention and Control Program revealed the plan was missing the required elements of: a) Criteria to define a system of surveillance for the identification of communicable diseases/infections to prevent the spread to other persons/residents in the facility based on the facility assessment b) Identify what infections, when and to whom the infections should be reported to c) Documented antibiotic process, outcome surveillance and action plans. Record review of the Infection Control Quality Reports dated 3/29/18 and 4/19/18 did not reveal surveillance data analysis, action plans or antibiotic stewardship criteria. During an interview on 4/26/18 at 1:02 pm, the ICP stated there were no current infection control action plans or projects and the antibiotic stewardship program had not been implemented yet and was in draft form. 3) Water Management Program Review of the facility's policies from 4/23-27/18 revealed there was no program to manage the facility's water to prevent the risk of Legionella or other opportunistic water borne pathogens in the facility's water system. During an interview on 4/26/18 at 1:02 pm, the ICP further disclosed there was no water management plan for Legionella. 4) Resident #10 Indwelling Urinary Catheter Bag (a bag to collect urine from a tube inserted through the urinary tract into the bladder) During three random observations on 4/24/18 at 10:42 am, 4/25/18 at 9:14 am and 4/27/18 at 1:31 pm, revealed Resident #10 sitting in wheelchair with indwelling urinary catheter bag attached to underside of wheelchair. The catheter bag dragged on the ground as the Resident propelled his/her wheelchair throughout the facility. During an interview on 4/26/18 at 2:30 pm, Licensed Nurse (LN) #2 stated catheter bags should not be touching the floor. During an interview on 4/27/18 at 2:30 pm, the Chief Nursing Officer (CNO) stated the facility does not have a written policy and procedure in regards to indwelling urinary catheter care. The CNO stated the facility follows Lippincott Procedures and provided copies of Indwelling Urinary Catheter .Care and Management from online source, Lippincott Procedures, dated (MONTH) 17, (YEAR). Review of Lippincott Procedures Indwelling Urinary Catheter .Care and Management, dated (MONTH) 17, (YEAR), Guidelines read, Don't place the drainage bag on the floor to reduce the risk of contamination and subsequent catheter-associated urinary tract infections. 2020-09-01