cms_AZ: 17

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

Data source: Big Local News · About: big-local-datasette

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rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
17 SANTA ROSA CARE CENTER 35004 1650 NORTH SANTA ROSA AVENUE TUCSON AZ 85712 2016-09-14 441 D 0 1 MTU811 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, observations, staff interviews and review of policy and procedures, the facility failed to ensure that proper hand washing techniques were implemented during pressure ulcer treatments for two residents (#34 and #145). Findings include: -Resident #34 was readmitted on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. A review of the clinical record revealed that on (MONTH) 14, (YEAR), one stage 4 pressure ulcer was still present on the resident's right hip. The (MONTH) (YEAR) recapitulation of physician's orders [REDACTED]. A pressure ulcer treatment observation was conducted on (MONTH) 14, (YEAR) at 9:30 a.m. At this time, the LPN (Licensed Practical Nurse/staff #127) was observed to wash her hands, donn gloves and cleansed the stage 4 pressure ulcer on the resident's right hip. Staff #127 was then observed to remove her gloves and donn another pair of gloves. Staff #127 then applied zinc oxide to the skin surrounding the pressure ulcer and proceeded to pack the pressure ulcer with the alginate and apply the border dressing. However, staff #127 was not observed to disinfect or wash her hands after cleansing the pressure ulcer and removing her gloves, after the application of the zinc oxide to the surrounding skin and prior to packing the pressure ulcer. An interview was conducted on (MONTH) 14, (YEAR) at 11:30 a.m., with staff #127. She stated that her usual practice was to only wash her hands at the beginning and the end of treatment. An interview with the Director of Nursing (DON/staff #109) was conducted immediately following this interview. Staff #109 stated that the LPN should have washed her hands after she cleansed the pressure ulcer and removed her gloves, after she applied the zinc oxide and prior to the application of the alginate and dressing. Staff #109 stated that the purpose of handwashing is for infection control and to not spread any bacteria that may be present. -Resident #145 was admitted to the facility on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Review of the clinical record revealed documentation that as of (MONTH) 14, (YEAR), two stage 4 pressure ulcers were still present on the right and left ischium. A pressure ulcer treatment observation was conducted on (MONTH) 14, (YEAR) at 10:13 a.m., with a LPN (staff #127). The LPN was observed to wash her hands, donn gloves, and then removed the soiled dressing from the resident's left ischium pressure ulcer. Staff #127 did not remove her gloves or wash her hands, after removing the soiled dressing. Using the same gloved hands, she cleansed the pressure ulcer with puracyn and packed it with calcium alginate. Staff #127 then removed her gloves, however; she was not observed to wash her hands or use a disinfectant. She then proceeded to donn clean gloves, removed the soiled dressing from the resident's right ischium pressure ulcer, cleansed it with puracyn, and packed the wound with the calcium alginate. She was not observed to change her gloves, wash her hands or use a disinfectant, after removing the soiled dressing from the resident's right ischium pressure ulcer. An interview was conducted with staff #127 on (MONTH) 14, (YEAR) at 11:44 a.m. She stated she should have washed her hands, after the removal of the soiled dressings and before she started the treatment. She also stated that handwashing should have been done between the treatments of the two pressure ulcers. An interview was conducted with the the DON (staff #109) on (MONTH) 14, (YEAR) at 11:50 a.m. He stated that handwashing was required between the removal of soiled dressings and before treatment was provided. He also stated that good handwashing needed to be done between the treatments of the pressure ulcers to aid in preventing infection. A facility policy titled, Handwashing/Hand Hygiene included the following: Objective-to prevent and control the spread of infectious disease. The policy also included the following: 3. The use of gloves does not replace handwashing. 4. If hands are not visibly soiled, use an alcohol based hand rub for all of the following: e. Before handling clean or soiled dressings, gauze pads, etc.; f. Before moving from a contaminated body site to a clean body site during resident care; h. After handling used dressings, contaminated equipment, etc.; j. After removing gloves. Another facility policy titled, treatment of [REDACTED]. Wash your hands thoroughly with soap and water at the following intervals: d. When changing/removing gloves or any personal protective equipment. 2020-09-01