cms_GU: 36
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 36 | GUAM MEMORIAL HOSPITAL AUTHORITY | 655000 | 499 NORTH SABANA DRIVE | BARRIGADA | GU | 96913 | 2016-09-29 | 441 | E | 0 | 1 | H7FJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility did not establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of diseases and infection. Findings include: 1. Random Sample Resident (RSR)11 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the physician's order dated 9/13/16 revealed an order for [REDACTED].; 0.125% IR starting on 9/13/16 twice daily for 30 days. Special Instructions: wet to dry dressing change with Dakin's solution 0.125% twice a day (BID) after cleaning with Normal Saline Solution (NSS) on sacrum and back area. Review of the Medication Administration Record from 9/19/16 to 9/27/16 revealed that wet to dry dressing change with Dakin's solution 0.125% BID after cleaning with normal saline solution on sacrum and back BID On 9/27/16 at 9:45 a.m., a licensed nurse (LN)2 was observed for pressure ulcer dressing change for Random Sample Resident (RSR)11. The nurse wore an isolation gown, pair of clean gloves and mask. She stated the resident is currently on contact isolation due to MRSA of the wound. she then prepared the two packs of 4x4 gauze she was going to use. The first pack of gauze was opened in the top and the nurse poured normal saline solution to wet the gauze and the second pack of gauze was opened to the top and Dakin's solution was poured in the gauze inside the packet. The resident's pressure ulcers were observed to be located in the sacral and mid lower back. LN2 changed the dressing one site at a time. She removed the old dressing with minimal to moderate amount of bloody drainage and proceeded to the sink area to remove the used gloves. She proceeded to use the hand sanitizer before wearing a new pair of gloves. She proceeded to clean the pressure sore area with one of 4x4 gauze in the packet that was observed to be slightly wet and not soaked with normal saline solution (NSS). Interview of LN2 on the same day revealed that she acknowledged that the gauze she used were not fully saturated with NSS. Review of the facility Policy No. 6580-D18 on Wet to Dry Wound Care dated (MONTH) 2009 stated, 12. Saturate the 4x4 gauze pads with the prescribed cleaning agent. Pick up the moistened 4x4 gauze pad, and squeeze out the excess solution. After the pressure ulcer area was cleaned with the NSS, another gauze with Dakin's solution was inserted into the Stage IV pressure ulcer in the sacrum and the area was covered with a dry dressing. Review of the facility Policy No. 6580-D18 on Wet to Dry Wound Care dated (MONTH) 2009 stated, #16. Use sterile cotton-tipped applicators for efficient cleaning of tight fitting sutures, deep and narrow wounds, or wounds with pockets. Review of the wound assessment sheet dated 9/21/16 revealed a healing Stage 4 in the sacrum measuring 1.3 cm. long, 1 cm. wide and 1.5 cm in depth with sero-sanguinous discharge and mild odor. The wound assessment sheet dated 9/23/16 described the other pressure ulcer as healing Stage 3 in the mid lower back that measured 1.5 cm. long, 6.1 cm wide and 0.2 cm in depth with scanty red drainage and no odor. On 9/27/16 at 2 p.m. during an interview, LN2 stated that she used to use the cotton-tipped applicators when the wounds were deeper but now that the wounds are healing she has not been using them lately. LN2 removed the contaminated gloves and used the hand sanitizer before she wore a clean pair of gloves. She repeated the same dressing change procedure to the Stage 3 pressure ulcer in the lower back. Review of the facility Policy No. 6580-D18 on Wet to Dry Wound Care dated (MONTH) 2009 stated, #9. Discard the soiled dressing and gloves in the trash can. 10. Wash hands. #26. Dispose of all soiled equipment and supplies appropriately, and wash your hands. 2. Review of the hospital wide policy #7202-130 titled, Employee Health Services (EHS)Immunizations with an effective date of 05/22/2008 and revised on 09/2011 revealed that all employees (initial and existing) will be assessed for vaccination history and immune status for the required vaccine-preventable diseases. The required vaccination (except Varivax) are offered via EHS free of charge. Documentation of declination/refusal of vaccination is required for employees that refuse to participate in vaccination. This refusal form will be filed with the employee's health record. Out of the 37 names listed as staff in the SNU, 6 employees refused 10/28/15 flu vaccination and 6 staff refused the 2/6/16 flu vaccination offer. Review of the hospital wide policy #6202-180 titled: Methods of improving influenza vaccination rates amongst hospital employees and licensed independent practitioners with effective date of 5/22/13 revealed the presence of an Attachment III form related to influenza vaccination/declination surveillance. Although the form details the the information in tracking the reasons for the declination of the the influenza vaccine as part of performance improvement in infection control area, the policy did not address the preventive measures to protect the residents in SNU. On 9/28/16 at 3:30 p.m., interview with the EHS staff revealed that there was no facility policy on how health care workers who declined the influenza vaccination should take care of residents in SNU to reduce the potential of transmission of influenza and subsequent influenza-related complications during the vaccination period. 3. During the initial tour of the kitchen on 9/26/16, a sign on the cover of the ice machine noted, Not available for consumption. In an interview during the tour, DS11 stated that dietary staff were waiting for the results of a laboratory test on a culture that was recently obtained. Until then, DS11 stated, the ice can't be use. DS11 added that tests were conducted monthly. During the kitchen observation on 9/28/16, dietary staff stated that ice from the machine was safe to use and so the sign was removed. When a request was made to review the culture results, the staff stated that maintenance staff (MS1) had the information. During an interview on 9/28/16, the maintenance staff (MS1) stated a recent test revealed microbial growth so that the machine had to be cleaned, disinfected, and retested . The retest, according to MS1, noted no growth. Review of microbiology results provided by MS1 revealed that no growth was identified for tests from (MONTH) through (MONTH) (YEAR). In August, culture results from the ice machine dated 8/07/16 revealed the presence of 60 org/ml of non-fermenting gram-negative rods (that were) not Pseudomonas. In September, culture results dated 9/16/16 and 9/17/16 revealed the presence of 400 org/ml of Pseudomonas Stutzeri and 20 org/ml of Coagulase negative staph (staphylococcus), a gram-negative bacteria that can cause fever, chills, nausea, vomiting and other symptoms. There was no indication that the positive results were reported to infection control for appropriate surveillance and investigation, evaluation of safe food handling practices, and/or effectiveness of cleaning and maintenance service. | 2020-09-01 |