| 96 |
SENIOR REHAB & RECOVERY AT LIMESTONE HEALTH FACILI |
15024 |
1600 WEST HOBBS STREET |
ATHENS |
AL |
35611 |
2018-02-15 |
880 |
D |
0 |
1 |
EZGG11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of incontinent care on 02/14/2018 and medication administration on 02/13/2018, a review of the facility's policy's titled Urinary Catheter Care and Hand Hygiene, as well as staff interviews, the facility failed to ensure: 1) A Licensed Practical Nurse (LPN) did not place her ungloved fingers inside medication crush pouches to empty the crushed medications for administration of Resident #58's medications: [REDACTED] 2) A Certified Nursing Assistant (CNA) failed to wash her hands after removing soiled gloves and before putting on clean gloves during the provision of incontinence care. The CNA then touched clean items, including linens and Resident Identifier (RI) #33's clean brief and gown. These failures affected one of four nurses observed during medication pass observations and one of one incontinent care observations, involving RI #58 and RI #33. Findings Include: A review of Potter and Perry, Ninth Edition: FUNDAMENTALS OF NURSING Chapter 32 Medication Administration, page 656, documented: . (1) . Do not touch medication with fingers. (2) To prepare unit-dose tablets . place tablet . directly into medicine cup . A review of a facility policy titled: Hand Hygiene with a date of 07/30/16 documented: . 2. Indications for Hand Hygiene Always perform hand hygiene in the following situations: . After glove removal . 1) RI #58 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #58's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 12/11/17 revealed RI #58 was severely impaired in cognition (with a Brief Interview for Mental Status score of 4 of a possible 15). On 02/13/18 at 7:10 p.m., LPN/Employee Identifier (EI) #6 administered medication to RI #58. EI #6 placed [MEDICATION NAME] 20 milligram (1 tablet) in a crush pouch and crushed the medication. EI #6 opened the pouch with her ungloved fingers and emptied the medication into a medication cup. EI #6 placed [MEDICATION NAME] 50 mg (1 tablet) in a crush pouch and crushed the medication. EI #6 opened the pouch with her ungloved fingers and emptied the medication into medication cup. On 02/13/18 at 7:23 p.m., an interview was conducted with EI #6. EI #6 was asked what did she do when opening the medication pouch. EI #6 explained she had put her bare fingers in the pouch and should have put a glove on, to prevent contamination. On 02/15/2018 at 5:37 p.m., an interview was conducted with the Director of Nursing/Infection Control Director, EI #2. EI #2 was asked why should staff not use ungloved fingers to open a medication crush pouch. EI #2 responded, to prevent cross contamination. 2) RI #33 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #33's Quarterly MDS with a ARD of 11/22/17 revealed RI #33's BIMS score of 2, indicating severe cognitive impairment, dependent upon staff for toileting and hygiene needs, and incontinent of bowel function. RI #33's hospital DISCHARGE SUMMARY dated 01/04/18, documented: . DISCHARGE Diagnosis: [REDACTED]. On 02/14/18 at 5:45 p.m., Certified Nursing Assistant, EI #7 provided incontinent care for RI #33 in the presence of the surveyor. RI #33 rolled to the left side of the bed, EI #7 wiped the buttock area three times front to back, using a clean wash cloth with each wipe. Bowel movement was visible on the wash cloth after each wipe. EI #7 wiped RI #33's catheter tubing, after which RI #33 rolled self onto his/her back. Without removing her dirty gloves, washing hands and changing gloves, EI #7 then placed a clean brief under RI #33 and put a clean gown on the resident. On 02/14/18 at 6:00 p.m., the surveyor asked EI #7 if she had washed her hands or changed soiled gloves. EI #7 said she had not, but she should have, due to contamination. When asked if she should have handled the clean brief, clothes and clean linen with soiled gloves, EI #7 replied, no because of contamination to the items. On 02/15/18 at 5:37 p.m., an interview was done with EI #2, the DON and Infection Control director. EI #2 said staff should wash hands after taking off soiled gloves and before putting on clean gloves to prevent the spread of infection. EI #7 said staff should never touch clean items/linen with soiled gloves to prevent the spread of infection. |
2020-09-01 |