| 53 |
ATHENS HEALTH AND REHABILITATION LLC |
15016 |
611 WEST MARKET STREET |
ATHENS |
AL |
35611 |
2018-07-19 |
880 |
D |
0 |
1 |
OEFS11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and a review of the facility policies titled Hand Hygiene, Blood Glucose/PT/INR Machine Cleaning Guidelines, and Using Gloves, this facility failed to ensure that infection control practices were utilized to prevent the spread of infection. This deficient practice had the potential to affect 3 of 3 residents, RI #'s 57, 49 and 313. Findings include: A review of the facility's policy Infection Prevention & Control Manual, Policy Title: Hand Hygiene, effective date (MONTH) 1, (YEAR), Purpose: To provide guidelines to employees for proper and appropriate hand washing techniques that will aide in the prevention of the transmission of infections. Standard: Hand washing should be performed between procedures with resident/guest(s) based upon the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucus membranes may contain transmissible infectious agents. III. Hand Hygiene Hand hygiene continues to be the primary means of preventing the transmission of infections. The following is a list of some situations that require hand hygiene. * .before and after direct residnet/guest contact . Before and after perfoerming any invasive procedure (e.g. fingerstick blood sampling). A facility policy titled, Using Gloves dated (MONTH) 1, 2009 revealed, Standard: Gloves should be worn when . possibly infectious materials are anticipated. A facility document titled Blood Blucose/PT/INR Machine Cleaning Guidelines with a revision date of 11/5/11 included the following: 3. Don first pair of gloves, do procedure, place glucometer on contaminated towel/surface. 4. Wash hands and put on a second pair of gloves. 5. Clean glucometer with disinfectant wipe, place on clean surface . EI (Employee Idenntifier) #7 Licensed Practical Nurse (LPN), was observed during the medication pass observation on 7/17/18 at 3:39 PM. 1. At 3:45 PM, EI #7 performed a finger stick blood sugar (FSBS) on RI #57. After obtaining the FSBS, EI #7 was observed to remove her gloves, and not perform hand hygiene. EI #7 cleaned the glucometer with her bare hands and placed the glucometer bck on the same barrier (unclean surface). Hand hygiene was not performed until after the staff cleaned the glucometer. 2. At 3:56 PM, EI #7 obtained a FSBS on RI #49. EI #7 was then observed to reach down into a magazine basket with her gloved hand. After EI #7 removed her gloves and cleaned the glucometer before performing hand hygiene. 3. On 7/17/18 at 4:05 PM, hand hygiene was not done before putting on gloves and performing a FSBS on RI #313. At 4:10 PM, EI # 7 cleaned the glucometer but did not do hand hygiene till after she cleaned machine. EI #7 gave RI #313 insulin but did not wear gloves while doing so. Again at 5:02 PM, EI #7 gave RI #313 insulin and did not wear gloves. [MEDICATION NAME] 10 units in the right upper abdomen, no gloves were worn. On 7/18/18 at 4:29 PM, an interview was conducted with EI #7, LPN. EI #7 was asked when she should wash her hands during med pass? EI #7 replied, before and after each med pass and each resident. EI # 7 was asked, what is the potential for harm of not performing hand hygiene? EI #7 replied infection, bacteria, and spreading germs. On 7/18/18 at 4:29 PM, EI #7 was asked what she should have done before cleaning the glucometer? EI # 7 replied, put on gloves EI #7 was asked, what should you do before putting soiled glove in a resident's magazine rack? EI #7 replied, I don't know, took that glove off and put another glove on. When asked what should be worn before you give an injection? EI #7 replied, Gloves. When asked what is the potential for harm? EI # 7 replied,spreading germs. On 7/18/18 at 4:07 PM, an interview was conducted with EI #5, the Director of Nursing (DON). EI #5 was asked, during med pass, when should the nurse wash their hands? EI#5 replied, when they enter the room, before they prepare medications, and if they touch anything they need to (wash their hands) before they go back to the med cart. EI #5 was asked what should be done before putting a soiled gloved hand in resident's magazine rack? EI #5 replied, Remove glove before touching anything in the environment. EI #5 was asked, what should be worn before you give an injection? EI #5 replied, Need to have gloves on. EI #5 was asked, what is the potential harm? EI #5 replied, infection to the residents. |
2020-09-01 |