| 3 |
BURNS NURSING HOME, INC. |
15009 |
701 MONROE STREET NW |
RUSSELLVILLE |
AL |
35653 |
2019-08-21 |
880 |
D |
0 |
1 |
HHU111 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, medical record review and review of Potter and Perry, Fundamentals of Nursing, Ninth Edition, the facility failed to ensure a licensed nurse: 1. cleaned Resident Identifier (RI) #32's nasal spray prior to recapping, 2. removed gloves and washed hands and applied clean gloves after administering RI #32's inhaler prior to administering his/her nasal spray, 3. cleaned RI #32's inhaler prior to recapping, 4. cleaned RI #32's [MEDICATION NAME] syringe prior to placing it back in a plastic sleeve, and 5. cleaned and dried RI #32's nebulizer mask and reservoir prior to storing it in a plastic bag. This affected RI #32, one of four residents observed during medication pass observation and one of two nurses observed. Findings Included: A review of of Potter and Perry, Fundamentals of Nursing, Ninth Edition, Chapter 29, Infection Prevention and Control, page 455, documented: .Cleaning. Cleaning is the removal of organic material .from objects and surfaces .When an object comes in contact with an infectious or potentially infectious material, it is contaminated .Reusable objects need to be cleaned thoroughly before reuse . RI #32 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 08/21/19 at 7:56 a.m., during medication pass observation, Employee Identifier (EI) #1, Licensed Practical Nurse (LPN), was observed administering RI #32's inhaler while wearing gloves. She then proceeded to administer RI #32's nasal spray while wearing those same gloves. EI #1 also recapped RI #32's nasal spray and inhaler without wiping or rinsing them off and returned a syringe used to administer RI #32's sublingual [MEDICATION NAME] back into a plastic sleeve without rinsing it prior to storing it in the medication cart. EI #1 was then observed returning RI #32's nebulizer mask and tubing back into a plastic bag without emptying the residue, rinsing and drying the reservoir. On 08/21/19 at 1:31 p.m., an interview was conducted with EI #1, LPN. EI #1 was asked what should she do after a resident has used an inhaler. EI #1 said wipe it off with a Kleenex or something like that. EI #1 was asked what should she do after a resident has used a nasal spray. EI #1 replied, same thing, wipe it off with a Kleenex or something. EI #1 was asked did she clean the inhaler before placing the cap back on it and storing it in the medication cart. EI #1 responded, no. EI #1 was asked did she clean the nasal spray after administering it to RI #32. EI #1 said no. When asked when she should wash her hands and change gloves during medication pass with different routes, EI #1 stated after each route. EI #1 was asked did she remove her gloves, wash her hands and apply clean gloves after administering RI #32's inhaler, before administering his/her nasal spray. EI #1 said no, she should have removed her gloves and went and washed them right then and put on a clean pair. EI #1 was asked did she clean the syringe used to administer RI #32's [MEDICATION NAME] before returning it to the medication cart. EI #1 replied no. EI #1 was asked what should she do after administering a nebulizer treatment before storing the tubing and pipe back in the plastic bag. EI #1 said she should have wiped it. EI #1 was asked did she pour out the residue after RI #32's treatment. EI #1 stated no. EI #1 was asked what was the concern with these issues. EI #1 answered infection control. On 08/21/19 at 4:18 p.m., an interview was conducted with EI #2, Registered Nurse/Infection Control Preventionist. EI #2 was asked, when should a nurse change gloves and wash her hands during medication pass. EI #2 said, before she goes in, after she finishes and each time she goes from one route to another she should change her gloves and wash her hands or at any time she was not sure if she had touched something. EI #2 was asked, what should a nurse do with an inhaler and/or nasal spray bottle after administration and prior to storing back in the medication cart. EI #2 replied, wipe or wash the mouthpiece or nasal tip if needed before placing it back in the plastic bag. EI #2 was asked, what should a nurse do after administering [MEDICATION NAME] sulfate by a syringe prior to storing it in the container. EI #2 replied, wash it and dry it and put it back in the container. EI #2 was asked what was the concern with not washing hands or changing gloves when needed or not cleaning inhalers, nasal sprays, nebulizer pipes and reservoirs prior to them being stored. EI #2 answered, spread of bacteria and infections. |
2020-09-01 |