cms_HI: 30
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 30 | KULA HOSPITAL | 125003 | 100 KEOKEA PLACE | KULA | HI | 96790 | 2017-04-21 | 441 | F | 0 | 1 | 1M3411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview with staff member, the facility failed to establish and maintain an effective infection prevention and control program including the tracking and analyzing of outbreaks of infection. Findings include: 1) On 4/13/17 at 9:00 [NAME]M. an interview was conducted with the Director of Nursing (DON) and Staff Member #122. The staff members were asked how they collect, trend and analyze their data related to infection control. Staff Member #122 reported the nurses will submit infection surveillance forms to report any concerns regarding infections as well as discuss infection issues in daily rounds. This information is collected for data and reviewed for trends. The staff member also reported the infection program also tracks the immunization process. The DON and Staff Member #122 confirmed the facility had an outbreak of Norovirus in (MONTH) (YEAR). The Norovirus reportedly was isolated to the 4th floor; however, a resident on the 3rd floor also had Norovirus. Further queried whether the facility determined the source of the Norovirus outbreak. Staff Member #122 responded it's impossible to figure it out; however, the facility makes note if a cruise ship was in the port and possibly the Norovirus may have come from the children visiting from the school or a staff member being infected from their child. The data and trends collected by the facility were not specific enough to identify the origin of the Norovirus. A request was made to review their infection log/data. The facility provided data from (MONTH) (YEAR) through (MONTH) 6, (YEAR). The data included the resident's name, medical record number, room number, type of infection, culture, antibiotic and comment. The staff members were queried whether the infection control program determines whether infections were hospital or community acquired. The response was they did not think this is part of the policy to track whether infections are hospital or community acquired. Further discussion confirmed the facility does not perform root cause analysis of infections. The facility did not develop an infection prevention and control program which includes analysis of outbreaks of infection (root cause analysis) to formulate corrective action and plan for continued prevention. 2) On 4/12/2016 at 8:40 AM observed Staff #180 prepare 2 prefilled syringes of normal saline and 2 prefilled syringes of [MEDICATION NAME] to do a PICC line flush for Resident #44. Staff #116 was present orientating Staff #180. Staff #180 opened the individual packaging of each syringe and placed all of the syringes on top of the resident's bed with no protective barrier between the bedding and the syringes. Staff #116 picked up all of the syringes on the bed and failing to wipe the table or use a protective barrier, placed the syringes on the resident's over bed table. Observed Staff #180 use each syringe to do the PICC line flush. After the procedure an interview was held with Staff #116 and Staff #180, regarding use of a protective barrier for the clean syringes. Staff #116 agreed a protective barrier should have been used for infection control practice. Failure to maintain a clean working environment when administering medications has the potential for development and transmission of infection. 3) On 4/12/2016 at 9:04 AM observed Staff #180 do a PICC line flush for Resident #44. Staff #116 was present orientating Staff #180. The PICC line had two ports. Staff #180 opened one line, did an alcohol wipe to the needleless hub, inserted the normal saline syringe tip into the hub, and pushed the normal saline flush through the PICC line. Staff #180 then disconnected the normal saline syringe and without doing an alcohol wipe to the hub connected a [MEDICATION NAME] syringe tip and pushed the [MEDICATION NAME] solution through the PICC line. Staff #180 then opened the second PICC line, wiped the PICC port with alcohol, connected the normal saline syringe and pushed the normal saline into the line. Staff #180 then disconnected the syringe and without doing an alcohol wipe connected a [MEDICATION NAME] syringe into the hub and pushed the [MEDICATION NAME] solution into the line. After the observation interviewed Staff #116 on the observation. Staff #116 was asked if an alcohol wipe should have been done prior to the [MEDICATION NAME] flush for each line. Staff #180 stated, no need to do the wipe because the port is still clean. A concurrent review of the facility policy was done with Staff #180. The policy for IV Site Care and Maintenance. Procedure 4. states, Scrub needleless injection cap prior to each entry with alcohol. Failure to do the recommended alcohol cleanse prior to each entry into the needleless IV port has the potential for development and transmission of infection. 4) On 04/10/2017 at 12:46 PM, during observation of the second floor nursing unit's lunch service, Staff #140 was observed sitting next to Resident #4 (R #4). Staff #140 was feeding the resident while she sat in bed. This resident had a contact isolation sign posted at the entrance to her room. The sign stated, Stop Check with nurse before entering room .Wear Gloves for all contacts, Wear Yellow Gown within 3 feet, If splashing possible wear face shield . The Nursing Home Administrator (NHA) was standing in the hallway with the surveyor and confirmed surveyor's observation that Staff #140 was not wearing any personal protective equipment (PPE), such as a disposable gown and gloves while assisting the resident to eat. The NHA asked the staff to stop feeding the resident and to wash her hands and come out of the room to wear the appropriate PPEs. Surveyor queried Staff #140 and asked why she was not wearing any PPEs. Staff #140 replied, I think when you're feeding, not supposed to. All I hear is we use iso gowns, gloves, mask when we doing patient care. The NHA told Staff #140 that it includes feeding this resident, and asked the staff to wear the appropriate PPEs before returning to the resident's bedside. On 04/10/2017 at 12:51 PM, the Staff #108 stated there was a new order from R #4's attending physician that said staff was to gown only for peri-care, but acknowledged the signage did not reflect that. Staff #108 also said the attending physician wanted to ensure the family who visits daily during dinner would be able visit without wearing the PPEs as a quality of life matter for this [AGE] year old resident. The NHA pointed out this was inconsistent for the staff as to what they are supposed to be following for contact isolation, and if there was any breach because of not wearing the PPEs, then there was a potential risk for transmission to others, such as other residents, staff and her visitors. On 04/11/2017 at 9:46 AM, chart review found the (MONTH) (YEAR) Physician's Order Statement said the resident is on contact isolation from 8/15/16 for a [DIAGNOSES REDACTED]. On 04/12/2017 at 9:42 AM, the DON provided their policy and procedure, Isolation Precautions, No. 125-400-040. It stated, V. [NAME] Contact Precautions: These precautions are to be used to reduce the risk of transmission of resistant microorganisms by direct or indirect contact with a patient and/or patient's environment .CDC recommends continuing Contact Precautions routinely for ALL patients colonized or infected with MDROs. Gowns and gloves should be worn at a minimum. Masks are worn if splashes or projectile secretions are possible .HCWs (Health Care Workers) should always explain the necessity of PPEs and expanded precautions to the patient, patient's family and visitors. The facility failed to ensure staff followed the contact isolation precautions increasing the risk and potential for transmission of disease. | 2020-09-01 |