| 98 |
SENIOR REHAB & RECOVERY AT LIMESTONE HEALTH FACILI |
15024 |
1600 WEST HOBBS STREET |
ATHENS |
AL |
35611 |
2019-03-20 |
880 |
D |
0 |
1 |
ITMZ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of a facility policy titled, Dressing - Clean, the facility failed to ensure staff gloves were removed and hand hygiene was performed after cleaning a sacral wound and before applying ointment and touching other parts of the resident's body, pillow, blanket and bed remote. This affected Resident Identifier (RI) #65, one of 2 residents observed for wound care. Findings include: A facility policy titled, Dressings-Clean, with an effective date of (MONTH) 1, 2001, revealed: . Process: . 13. Remove gloves and wash hands. A facility policy titled, Hand Washing, with an effective date of (MONTH) 1, 2001, revealed: . Standard: Hand washing should be performed between procedures with residents. RI #65 was readmitted to the facility on [DATE] with two sacral ulcers. [DIAGNOSES REDACTED]. Review of the resident's physician's orders [REDACTED]. On 03/19/19 at 10:14 am, the surveyor observed pressure ulcer care provided by Employee Identifier(EI) #2, the facility Certified Registered Nurse Practitioner, and EI #4 Registered Nurse/Wound Nurse, to RI #65. EI #2 was observed to remove the dressing to the sacral area and discarded it into the trash container. She then discarded the gloves into the trash container, washed her hands in the bathroom sink and applied new gloves. EI #4 stated this was a new wound area from around the (MONTH) 15 th, 2019. EI #2 cleaned the sacral area wound with normal saline applied to folded gauze handed to her by EI # 4. EI#2 then wiped the wound on the sacral area with the gauze. EI #2 proceeded to touched the resident on the gown with the same gloved hand. EI #2 applied [MEDICATION NAME] powder mixed with Venalex ointment from a medicine cup with a Q-tip. After applying the ointment EI #2 then touched RI #65's pillow under the resident's head, the resident's arm and then the blanket lying on the bed, pulling it up over RI #65's, wearing the same soiled gloves. EI #2 picked up the bed remote, operated it lowering the bed and touched the resident's left upper arm. EI #2 then removed the gloves and threw them in the trash container. On 03/19/19 at 01:40 pm, the surveyor interviewed EI #2. She was asked what should she do in between wound care and contact with other items in the resident's room. EI#2 replied she should remove the gloves and wash her hands if it is contaminated. EI #2 was asked did she touch other items in the residents room with the same gloves on after she cleaned the sacral wound with the saline gauze and applied ointment. EI#2 replied she did, but her hand was not contaminated. EI #2 was asked after caring for the wound, what items in the resident's room did she touch with those same gloves on. EI#2 replied she touched the patient, the bed linens, and she touched the resident's bed control. She said it was not a draining wound and she never came in contact with the wound bed. The surveyor asked what was the potential harm when you are caring for a wound and then touch other items in the room with the same gloves on. EI #2 responded, that could be contamination and cross contamination if the gloved hand was contaminated. On 03/19/19 at 04:40 pm, the surveyor interviewed EI #1, Assistant Director of Nursing. EI #1 was asked what should staff do after cleaning and applying ointment to a sacral wound before touching other objects in a resident's room. EI #1's response was they should take the gloves off, dispose of them properly and wash their hands properly. The surveyor asked what was the potential harm for using the same gloves worn to clean a wound and apply ointment and then touching the pillow under the resident's head. EI #1 replied you have a potential to spread germs. |
2020-09-01 |