| 73 |
MERRY WOOD LODGE |
15019 |
P O BOX 130 |
ELMORE |
AL |
36025 |
2018-03-29 |
880 |
D |
0 |
1 |
OSF111 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and the review of facility policies, Waste Management, Medication Administration, Hand Hygiene, Glucose Meter, and Cleaning and Disinfecting, the facility failed to ensure: 1. medications were not placed on an unclean surface for RI (Resident Identifier) #22 and RI #55, 2. a glucose monitor was not placed on an unclean surface for RI #55 and then used for the resident, 3. hands were washed during medication administration, 4. gloves were used when handling the enteral infusion administration set, 5. a Gastrostomy tube infusion administration set was not covered with a unclean plastic cover and 6. a nurse did not dispose of a used glucose test strip in a trash can after use for RI #55 in his/her room. This affected RI #22, and RI #55, two of eleven residents observed during medication administration. Findings Include: A review of a facility policy and procedure, titled, Hand Hygiene with a revision date of 11/28/17, revealed: . POLICY Adherence to hand hygiene practices is maintained by all Center personnel. PR[NAME]ESS 1. Perform hand hygiene 1.1 Before patient care; . 1.4 After patient care; 1.5 After contact with patient's environment . A review of a facility policy and procedure titled, Cleaning and Disinfecting, with a revision date of 11/28/17, revealed: . PURPOSE To prevent infectious spread from items or environment to patients and/or staff. To ensure reusable medical equipment is cleaned and disinfected appropriately. PRACTICE STANDARDS . 5. Clean environmental surfaces, . using Environmental Protection (EPA) registered disinfectant . A review of a facility policy and procedure titled, Glucose Meter with a revision date of 5/15/17, revealed: .Glucose Meter 1. Gather equipment: . 2. Disinfect meter before and after each . use. A review of a facility policy and procedure titled, Waste Management, with a revision date of 10/31/16, revealed: . POLICY The Center's waste disposal system includes separate methods for handling regulated and non-regulated waste. These different types of waste are segregated . DEFINITIONS Regulated waste is also referred to as .medical waste . The Occupational Safety and Health Administration (OSHA) defines regulated waste as: Any liquid or semi-liquid blood or other potentially infectious material . PURPOSE To reduce risk of contamination from regulated waste and maintain appropriate handling and disposal of all waste . A review of RI #22's medical record revealed the resident was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of an Admission MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 01/07/18, revealed RI #22 was cognitively impaired with both long term and short term memory. The MDS also revealed RI # 22 was totally dependent on facility staff for all ADLs (Activities of Daily Living). At 11:49 a.m., on 3/28/18 EI (Employee Identifier) #1, a LPN (Licensed Practical Nurse} was observed preparing medications. EI #1 removed two packages of pills and one bottle of liquid medication and placed them on top of the medication cart. EI #1 removed a pill from each of the pill dispensing cards. A pill fell out of one cup onto the floor. EI #1, was observed picking up the pill off the floor with her bare hands. EI #1 was not observed washing her hands prior to continuing to set up the medications for administration. After the medications were prepared EI #1 gathered all medications and entered RI #22's room. All medications were placed on the top of a table at RI #22's bedside. EI #1, with gloves on, picked up a remote control off the fall mat on the floor to raise the bed up and without changing gloves or washing her hands, EI #1 left the resident's room. EI #1 was observed returning to RI #22's room. EI #1 did not change her gloves or wash her hands. EI #1 picked up the remote control for the bed from the floor and raised the bed up. Without washing her hands or changing gloves, EI #1 disconnected the enteral infusion administration set from RI #22's gastrostomy tube. EI #1 removed an uncovered, unprotected cap off of the top of the IV pole and placed the cap on the end of the enteral infusion administration set. On 03/29/2018 at 3:07 p.m. an interview was conducted with EI #1, a LPN. EI #1 was asked what did the facility policy say about hand washing during resident care. EI #1 replied wash hands for any provisions of care for a resident, before providing care, and after providing care, touching the resident before and after, and before and after procedures for the resident. EI #1 was asked to explain to this surveyor what happened at the medication cart while preparing RI #22's medications for administration. EI #1 stated one tablet fell on the floor. EI #1 replied she picked the pill up and disposed of it in the sharps container, then she obtained another pill for the resident. EI #1 was asked if she omitted anything after picking up a pill off of the floor. EI #1 replied she should have washed her hands before continuing with the mediation pass. EI #1 was asked why should she have washed her hands after picking up something off of the floor. EI #1 replied the floor is dirty, hands were contaminated after picking something up off of the floor. EI #1 was asked when the medications were taken into the resident's room where were they placed. EI #1 replied on a table next to the resident's bed. EI #1 was asked if there was anything different that she should have done. EI #1 replied not really, she could not think of anything. EI #1 was asked if the table was clean or if a barrier had been placed on the table before the medications were placed on the table. EI #1 replied no, she did not do that, but she should have. EI #1 was asked if there was a concern of placing medications on an unclean surface or not using a barrier. EI #1 replied she really did not know, she was always told to use a barrier with eye drops. EI #1 was aked what was done with the tip of the enteral infusion administration tube. EI #1 replied she took a cap off the top of the tube feeding pole and capped the the end of the enteral infusion tube with it. EI #1 was asked what should have been done after picking up the remote control for the bed off the floor twice. EI #1 replied she should have washed her hands. A review of RI #55's medical record revealed the resident was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a Re-Admission MDS with an ARD date of 02/15/18, revealed RI #55 was cognitively impaired with both long term and short term memory. RI #55 was totally dependent on facility staff for all ADLs. On 03/28/2018 at 12:04 p.m., EI#1 was observed preparing to perform a finger stick with a blood glucose monitor for RI #55. The blood glucose monitor was removed from the medication cart and placed upon the top of an unclean medication cart. An alcohol pad, lancet, and blood glucose monitor strip was also obtained and placed on top of the unclean medication cart. EI #1 gathered all of the above supplies and entered RI #55's room, placing all of the above supplies on an unclean table top. EI #1 placed clean gloves on without washing her hands. EI #1 performed a finger stick blood glucose test. All equipment and supplies were returned to the top of the table. EI #1 picked up the testing strip, held it in her left hand and removed her gloves. EI #1 disposed of the gloves with the test strip inside the gloves into RI #55's trash can. EI #1 picked up the blood glucose monitor and lancet without washing her hands or putting on gloves. EI #1 then returned to the medication cart. EI #1 placed the blood glucose monitor on top of the medication cart. EI #1 obtained a disinfectant disposable cleaning wipe and with bare hands EI #1 cleaned the blood glucose monitor with her bare hands and placed it on top of an unclean medication cart with no barrier present. EI #1 obtained insulin to be administered to RI #55 from the medication cart. EI #1 entered RI #55's room with a syringe of insulin and alcohol wipe which both were placed on top of an unclean table, without a barrier. EI #1, without washing her hands, placed gloves on and administered RI #55's insulin. EI #1 was observed leaving RI #55's room to obtain supplies and a cap to cover the end of the enteral infusion set. EI #1 returned to RI #55's room and without washing her hands and using her bare hands capped the end of the enteral infusion set then left the room without washing her hands. On 03/29/18 at 3:49 p.m., an interview was conducted with EI #1. EI #1 was asked what happened in the process of preparing to perform a blood sugar stick for RI #55. EI #1 replied she took the glucose meter out of the medication cart and laid it on top of the medication cart without cleaning it or using a barrier, which contaminated the machine. EI #1 also said she obtained a lancet, test strip and alcohol pad and placed them on top of the unclean medication cart without a barrier. EI #1 was asked where she placed the glucose meter, lancet and alcohol wipe. EI #1 said she placed all of the items on the table next to RI #55's bed, put on her gloves and did not wash her hands. EI #1 was asked what she did with the test strip after completing the finger stick. EI #1 said she pulled her gloves off and kept the strip rolled up inside of the gloves and threw it into RI #55's trash can. EI #1 was asked what was the facility policy about disposing of medical waste with blood present. EI #1 said she should have put it in the trash can on the medication cart. |
2020-09-01 |