cms_GU: 87
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 87 | GUAM MEMORIAL HOSPITAL AUTHORITY | 655000 | 499 NORTH SABANA DRIVE | BARRIGADA | GU | 96913 | 2012-09-27 | 520 | E | 1 | 0 | KXEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record and document review, the facility failed to consistently implement and evaluate plans of action related to the identified quality deficiencies in infection control practices to prevent the development and transmission of infection and communicable diseases as evidenced by: 1. Failure to follow posted instructions for residents placed in contact isolation precautions. 2. Failure to inform and educate residents, families, and visitors of the necessary precautions 3. Failure to ensure adequate personal protective equipment was available and accessible when needed. 1. On 9/26/12 at approximately 3:50p.m., an RN staff member was observed going from room-to-room checking on residents. The nurse entered the room of sampled Resident #6 who was identified as being on 'Contact Isolation' precautions as evidenced by the sign posted at the entry outside of the resident's room. The sign stated that a staff member or visitor was to wear a protective gown and gloves (Personal Protective Equipment - (PPE)) when entering the resident room, as well as washing hands before entering and after exiting the room. Upon entering, the staff member did not wash her hands or put on a protection gown or gloves as indicated on the contact isolation precaution sign posted at the doorway. While in the room, the resident complained of left flank discomfort. The staff member proceeded to pull-up the resident's gown and palpated/examined the left side of the resident' s torso. After she finished the encounter with the resident, she left the room without washing her hands and continued to enter other resident rooms interviewing and assessing residents after the start of the evening shift. At approximately 4:32 p.m. the RN staff member was interviewed. She stated that she was doing her 'rounds' to check on residents as she normally does after the start of her shift. The staff member acknowledged that she did not wear a protective gown or gloves when entering the resident room. She also acknowledged that she did not wash her hands before or after the encounter with the resident and should have adhered to the instructions on the posted contact isolation precaution sign. Resident #6 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident's medical record indicated that the resident was placed on contact isolation related to the [DIAGNOSES REDACTED]. On 9/26/12 at approximately 10:15 a.m., a staff member was observed entering into Resident room [ROOM NUMBER] that had contact isolation precautions signage posted at the entry door. The sign read that staff and visitors were to wear a protective gown and gloves (Personal Protective Equipment - (PPE)) when entering the resident room, as well as washing hands before entering and after exiting the resident room. The staff member did not wash her hands prior to entering, did not put on gloves or a protective gown (all of which were located outside the resident room in a storage cart marked PPE (Personal Protective Equipment). She then proceeded to examine the resident making contact and moved the IV pole located at bedside of the resident who was sitting in a wheelchair at the time. She then left the room (without washing her hands), and proceeded to go enter a different room (107) without washing her hands and had direct contact with her hands to the resident in that room. After staying in that room for about one minute, she then returned to room [ROOM NUMBER] without washing hands, putting on gloves, or wearing protective gown and removed the IV medication tubing that was connected to the arm of the patient. She then touched and checked the IV site on the patient, and then exited the room. After disposing of the IV tubing, she went directly to the nursing station, where she still did not wash her hands. During an interview at approximately 10:30 a.m., the staff member was asked about the resident being on contact isolation precautions. She stated that most of the patients that are admitted with amputations or skin ulcers are placed on contact isolation precautions when admitted to the facility as a precaution. Further, she stated that she did not realize she had not washed her hands. 2. Unsampled Resident #7 was in room [ROOM NUMBER] and had been admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident was assessed to be alert and oriented by the facility. During an interview with the unsampled resident on 9/26/12 at approximately 11:30 a.m., he stated that he did not know why he had been placed on isolation precautions, and that no one from the facility had told him why he was on contact isolation precautions. On 9/26/12 at approximately 10:00 a.m., unsampled Resident #8 was observed in his room with a visitor. The resident had been placed on contact isolation precautions as indicated by the sign on at the entrance of his room. The sign stated that staff and visitors were to wear a protective gown and gloves (Personal Protective Equipment) when entering the resident room, as well as washing hands before entering and after exiting the resident room. The visitor was sitting in a facility wheelchair at the bedside of the resident talking to the resident who was in bed, and was sharing a telephone conversation via the visitor's cell phone. At approximately 10:45 a.m., the resident was interviewed and stated that he did not realize he was on contact isolation precautions. He had no idea what the term meant, and that no one at the facility had told him or his brother that had been visiting. The resident said he routinely receives visits from family members and friends daily, and that no one wears gowns or gloves when visiting because they don't know they are supposed to. According to the medical record, the resident had been admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident was assessed to be alert and oriented by the facility, and had been placed on isolation precautions at the time of admission. 3. On 09/26/2012, beginning at 9:30a.m., during a tour, a sign was observed posted at the doorway of room [ROOM NUMBER]. The sign indicated Contact Isolation and listed instructions to gown and glove before entering the room, clean hands before entering room and upon exiting clean hands with soap and water, no gel soap can be used. Contact Precautions (Isolation) are intended to prevent transmission of infectious agents. which are spread by direct or indirect contact with the patient or the patient's environment . The application of Contact Precautions is for patients infected or colonized with multiple drug resistant organisms (MOROs). Contact Precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission .Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination. 2007. Pdf> A cart (bedside table) was in front of room [ROOM NUMBER]. The staff member identified the cart as an isolation cart to store PPE (personal protective equipment) such as gowns, gloves, and masks and protective eyewear. When the three drawers on the cart were opened, the first drawer had two yellow gowns, the second drawer was empty and the third drawer had a half full12 ounce bottle of drinking water. The staff member removed the bottle of water immediately and validated only PPE should be stored in the cart. The staff member also stated the nurses did not stock the isolation carts. The nursing assistants were expected to restock when needed. Medical record review on 9/26/2012 at 2 p.m., revealed the resident in room [ROOM NUMBER] had a physician order for [REDACTED]. Based on the 2007 CDC guidelines for isolation techniques, the contact isolation sign for this resident should have indicated hand washing with soap and water or alcohol based hand rub. During an interview on 9/27/2012, beginning at 11 a.m., the administrative staff indicated they had developed two signs for contact isolation. One sign was for regular contact isolation and the second sign was for special contact isolation. The special contact isolation was designated to identify those patients who had contagious infections affecting the intestines causing frequent cramping and watery diarrhea. These infections could potentially be spread from one resident to another without good hand washing with soap and water only. The administrative staff had removed the incorrect isolation signs and replaced them with the correct instructions for staff by the following day. On 9/27/2012, a nutrition aide came to unit A at 12:15 p.m. to deliver the lunch trays. The first lunch tray was delivered to an isolation room. The nutrition aide was observed from the time she entered the unit. She walked directly to the food cart, removed a tray, delivered it to the resident in the isolation room, placed it on the table at bedside, left the room and immediately went back to the food cart to deliver the next tray. The next tray was delivered to a resident who required set up (opening of containers). As the aide was walking toward the food cart again, she was asked if this is the normal routine for her to pass all the trays on unit A. She indicated it was a daily routine and that they try to deliver the trays as soon as they arrive on the unit. When the aide was asked about hand hygiene between residents with or without isolation, she stated she does not touch the residents. No hand washing was observed prior to the start of serving the trays, before entering, or after leaving the residents rooms. The aide was observed washing her hands at the nurse station before the next tray was delivered. Review of the facility policy ' Personal Protective Equipment (SNU SPECIFIC) ' identified the types of personal protective equipment and appropriateness of use. Under suggested use for examination gloves, the policy directs the staff to use vinyl synthetic examination gloves for short term tasks such as handling and preparing food.Review of the facility policy 'Rationale for Isolation Precautions' identified indirect contact as the most frequent mode of transmission (spreading infection) .through a contaminated inanimate object and subsequently touch another resident without performing hand hygiene between resident contacts. The policy further indicated, Unwashed hands are the most frequent cause of pathogen (germ) transfer resulting HAIs (hospital/facility acquired infections). Review of the facility infection control skills validation and training list completed on 4/3/2012 identified 5 of 14 staff members were observed during a training scenario to perform a dirty procedure prior to performing a clean procedure (bowel/perineal care then oral care). 5 of 14 staff members failed to change gloves after first procedure. 2 of 14 staff members failed to perform hand hygiene between procedures. There was no evidence of remediation or further observations to ensure consistent, effective infection control staff practices. | 2015-09-01 |