cms_AZ: 46
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 46 | HANDMAKER HOME FOR THE AGING | 35016 | 2221 NORTH ROSEMONT BOULEVARD | TUCSON | AZ | 85712 | 2019-01-08 | 880 | E | 0 | 1 | ZWO111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, staff interviews, review of the Center for Disease Control (CDC) guidelines and policy and procedures, the facility failed to implement infection control measures for one resident (#222) on contact isolation precautions and failed to ensure infection control measures were implemented regarding catheters for two residents (#41 and #321). Findings include: -Resident #222 was admitted (MONTH) 4, 2019, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Physician orders [REDACTED]. A nursing progress note dated (MONTH) 4, 2019 at 3:30 p.m. revealed the resident was placed on isolation precautions. A care plan dated (MONTH) 5, 2019 revealed the resident had [MEDICAL CONDITION]. Interventions included the following: Contact Isolation: wear gowns and masks when changing contaminated linens; educate resident, family and staff regarding preventive measures to contain the infection; place in private room with contact isolation precautions and disinfect all equipment before leaving the room. An observation was conducted on (MONTH) 5, 2019 at 11:03 a.m., outside of resident #222's room. A visitor was observed inside the resident's room and was wearing a gown that was not secured, and was slipping off her shoulders. The visitor also only had one glove on her right hand. The visitor was observed moving items on and off the bedside table with both hands. During the observation, the visitor stepped into the hallway over the threshold, two times with the unsecured gown and one glove still on, and then re-entered the room. At one point, the visitor removed the gown and one glove, and placed them into the red biohazard bag by the door and exited the room. The visitor did not wash her hands prior to leaving the room. The visitor then picked up her personal items from the top of the isolation cart which was outside of the resident's room, and proceeded to leave the building without washing her hands. An interview was conducted on (MONTH) 5, 2019 at 11:42 a.m. with a Licensed Practical Nurse (LPN/ staff #85), who stated that when a resident is placed on isolation, there is a lot of education done with staff and visitors prior to entering the isolation room. Staff #85 stated that both staff and visitors are educated to put on a gown and gloves, secure the gown, and are taught proper removal of the gown and gloves. Staff #85 stated that staff and visitors are also educated to wash their hands with soap and water prior to exiting the room, because hand sanitizer is not effective. An observation was conducted on (MONTH) 5, 2019 at 12:09 p. m. of a Certified Nursing Assistant (CNA/staff #150) who put on a gown but did not secure it and donned gloves. Staff #150 briefly spoke to resident #222, then removed the gown and gloves and placed them into the red biohazard. Staff #150 then used hand sanitizer and exited the room. Staff #150 did not wash her hands with soap and water prior to exiting the room. Immediately following the observation, staff #150 stated that because she did not touch anything in the room, the hand sanitizer was acceptable to use. An observation was conducted on (MONTH) 5, 2019 at 12:21 p.m., outside of resident #222's room. At this time, the resident's call light was on. The administrator (staff #147) was observed to walk into resident #222's room carrying a notebook, without donning a gown or gloves. Staff #147 then set the notebook on the resident's bedside table which was next to the resident and then reached over the resident to turn off the call light. Staff #147 conversed with resident #222, then picked up the notebook from the bedside table and walked out of the room, without washing his hands. Immediately following the observation, an interview was conducted with staff #147 who stated that the facility policy for entering a contact isolation room is to put on a gown and gloves, prior to entering the isolation room. Staff #147 said that before exiting the room, remove the gown and gloves, dispose of them in the red biohazard bag inside the room, and wash your hands with soap and water. Staff #147 stated that hand sanitizer would not be acceptable to use when leaving an isolation room. Staff #147 stated he did not do any of those things when he entered and exited the room. Staff #147 then proceeded to apply hand sanitizer to his hands, however, did not wash his hands with soap and water. An interview was conducted on (MONTH) 7, 2019 at 10:13 a.m. with a LPN (staff #151), who stated that when a resident is on contact isolation precautions, the person entering the room should use hand sanitizer prior to applying a gown and gloves, and tie the gown around their neck and waist to secure the gown. Staff #151 said that before exiting the room, the gown and gloves should be removed and placed into the red biohazard bag inside the room, then wash their hands with soap and water. Staff #151 stated that soap and water will ensure the [MEDICAL CONDITION] spores are killed, as hand sanitizer is not effective. An interview was conducted on (MONTH) 8, 2019 at 8:39 a.m. with the Director of Nursing (staff #160), who stated when a resident is on isolation precautions, an isolation cart is set up outside of the resident's room. Staff #160 stated for contact isolation precautions, all people who enter the room, including staff and visitors are to put on a gown and gloves, prior to entering the room every time they enter. Staff #160 said that prior to leaving the room, the person should remove the gown and gloves and dispose of them in the designated biohazard trash bag. Staff #160 stated the person should then wash their hands with soap and water and exit the room, without touching anything else in the room. Review of the facility's Infection Control policy revealed the purpose is to minimize as far as possible, the risks of harm to staff, residents, volunteers, family members and visitors, which may arise through pathogens being passed from one person to another. Staff and residents are most likely sources of infectious agents and are also the most common susceptible hosts. Other people visiting the premises may be at risk of both infection and transmission. The facility ensures effective implementation of infection control. Hand washing and hand care are considered the most important measures in infection control. Effective infection control is central to providing high quality support for residents and a safe work environment for the facility's employees, board members and visitors. Infection control is integral to resident support, not an additional set of practices. Risks of infections are regularly assessed, identified, and managed and mechanisms are put in place for compliance with infection control procedures. Review of a policy regarding Transmission-Based Precautions revealed it is our policy to take appropriate precautions to prevent transmission of infectious agents. Transmission-based precautions are additional controls based on a particular infectious agent and the agent's mode of transmission. These precautions are to be used in adjunct with standard precautions. The policy further included an order for [REDACTED]. Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. Donning personal protective equipment (PPE) upon entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g. [MEDICAL CONDITION], norovirus and other intestinal tract pathogens). Review of the CDC guidelines revealed that [MEDICAL CONDITION] is a spore forming bacterium that causes inflammation of the colon known as [MEDICAL CONDITION]. [MEDICAL CONDITION] spores are shed in feces and transferred to patients mainly via the hands of people who have touched a contaminated surface or item. For the prevention of transmission of [MEDICAL CONDITION] in healthcare settings, use contact precautions for patients with known or suspected [MEDICAL CONDITION]. The guidelines included to use gloves and gowns when entering patient rooms and during care and for all interactions that may involve contact with patient or potentially contaminated areas in the patients environment. The guidelines also stated that before exiting the patient room, discard gowns and gloves, and wash hands with soap and water to contain the [MEDICAL CONDITION] pathogens. -Resident #41 was admitted (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. Review of a care plan dated (MONTH) 22, (YEAR) revealed the resident had an indwelling catheter for [MEDICAL CONDITION] bladder. The goal included the resident will have no signs or symptoms of a UTI through the next review date. Interventions included the following: -position tubing below the level of the bladder. -monitor and document for pain/discomfort due to the catheter -monitor/record/report to MD for signs or symptoms of UTI including pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, foul smelling urine, fever and chills. The quarterly Minimum Data Set (MDS) assessment dated (MONTH) 28, (YEAR) revealed the resident had a Brief Interview of Mental Status (BIMS) score of 3, indicating severe cognitive impairment. This MDS also revealed the use of an indwelling catheter. Review of the physician's orders [REDACTED]. During a random observation conducted on (MONTH) 6, 2019 at 8:31 a.m., resident #41 was in bed and the catheter bag was hanging on the bed rail, and approximately 5 inches of the catheter tubing was on the floor. Another observation was conducted on (MONTH) 6, 2019 at 2:49 p.m. of the resident in bed. The catheter bag was observed hanging on the bed rail and approximately 3-4 inches of the catheter tubing was on the floor. An interview was conducted on (MONTH) 7, 2019 at 10:13 a.m. with a Licensed Practical Nurse (LPN/staff #151), who stated that when a resident has a catheter, it is never acceptable for the catheter bag or tubing to be on the floor for infection control prevention. An interview was conducted on (MONTH) 7, 2019 at 1:56 p.m., with a Certified Nursing Assistant (CNA/staff #2). Staff #2 stated that the catheter tubing comes with a clip so it can be secured so it does not drag on the floor. Staff #2 stated that if the tubing drags on the floor, the entire tubing would have to be replaced by the nurse, because the tubing would be contaminated, as it would pick up germs from the floor, and those germs should not be transferred to the resident from the catheter tubing. An interview was conducted on (MONTH) 8, 2019 at 8:39 a.m. with the Director of Nursing (staff #160), who stated that catheter tubing should not be dragging on the floor for infection control purposes. -Resident #321 was admitted on (MONTH) 30, (YEAR), with the [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. An observation was conducted at 11:25 a.m. on (MONTH) 5, 2019, of the resident lying in bed. The resident's catheter bag was hanging under the bed facing the door, and the catheter tubing and the catheter bag was observed touching the floor. Another observation was conducted at 12:01 p.m. on (MONTH) 6, 2019, of a certified nursing assistant (CNA/staff #171) pushing the resident in the wheelchair down the hallway to the dining room. During the transport, approximately 4 inches of the catheter tubing was observed dragging on the floor. At 12:30 p.m. on (MONTH) 6, 2019, the resident was observed in the dining room eating lunch. The catheter tubing was observed resting on the floor under the wheelchair. At 12:55 p.m. on (MONTH) 6, 2019, staff #171 was observed pushing the resident in the wheelchair down the hall from the dining room to the resident's room. The catheter tubing was again dragging on the floor. Following the observation, an interview was conducted with staff #171. He stated that he did not see an issue with the catheter tubing dragging on the floor. He stated there was no way he could secure the tubing higher and prevent it from dragging on the floor. He then stated that he could tuck the tubing in the Foley bag and proceeded to tuck the tubing in the bag. An interview was conducted at 10:13 a.m. on (MONTH) 7, 2019, with a Licensed Practical Nurse (LPN/staff #151). She stated that the urinary catheter tubing or the Foley bag should never touch the floor. An interview was conducted with the Director of Nursing (DON/staff #160), who stated that all Foley drainage bags need to have a privacy bag and that the urinary catheter tubing should not be dragging on the ground. Review of policy and procedure for Catheter Care Urinary revealed the main goal is to prevent catheter-associated urinary tract infection. Under infection control, the policy included Be sure the catheter tubing and drainage bag are kept off the floor. | 2020-09-01 |