| 10 |
JEFFERSON DAVIS COMMUNITY HOSPITAL ECF |
255050 |
1320 WINFIELD STREET |
PRENTISS |
MS |
39474 |
2019-09-19 |
880 |
E |
0 |
1 |
S8KJ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based of observation, record review, staff interview, and facility policy review, the facility failed to provide a Percutaneous Endoscopic Gastrostomy (PEG) tube dressing change in a manner to prevent cross contamination for two (2) of two (2) resident PEG tube care sites observed, for Resident #23 and Resident #38. This was evidenced by allowing resident clothing to touch/cover the PEG site, after cleaning and prior to applying a dressing, during treatment for [REDACTED].#38. The facility also failed to provide wound care in a manner to prevent cross contamination for one (1) of four (4) resident wound care observations, Resident #31. This was evidenced by the RN touching items with ungloved hands prior to performing the treatment. Findings include: A review of the facility's policy titled, Infection Control Guidelines for all Nursing Procedures, with a revision date of (MONTH) (YEAR), revealed: Standard Precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious disease. A review of Perry and Potter Nursing Skills and Procedures, eighth edition, page 123, revealed: use of personal protective equipment reduces transmission of microorganisms. A review of facility policy titled, Policies and Practices-Infection control, dated (MONTH) (YEAR), revealed, The facility's infection control policies are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. A review of facility policy titled, Gastrostomy/Jejunostomy Site Care, dated (MONTH) (YEAR), revealed: The purpose of this procedure is to promote cleanliness and to protect the Gastrostomy or Jejunostomy site from irritation, breakdown and infection. Resident #31 On 9/18/19 at 9:48 AM, observation of wound care revealed RN #1 used her ungloved hands to place 10 dry 4 x 4 gauze dressings on a Styrofoam plate, sprayed the dressings with normal saline that she had gotten out of her treatment cart, then gloved and performed the wound care on Resident #31, using the 4 x 4 gauze. Resident #31's soiled dressing was observed to have a moderate amount serosanguious drainage. Resident #31's wound bed was pink with scattered red tissue. Resident #38 On 9/18/19 at 11:28 AM, an observation revealed, while RN #1 set up her supplies, she retrieved the 4 x 4 gauze dressings with her ungloved hands and placed them on a Styrofoam plate. She washed her hands, turned on the overbed light, and applied clean gloves, without washing her hands. She removed the soiled tube feeding dressing, washed her hands, applied clean gloves and performed the site care. On 9/18/19 at 11:48 AM, an interview with RN #1 revealed it was a habit for her to retrieve the 4 x 4 gauze with her bare hands and not use gloves. She also stated it made total common sense, that not wearing gloves while handling the 4 x 4 gauze dressings with bare hands, would cause cross contamination. On 9/18/19 at 11:50 AM, an interview with the Director of Nurses (DON) revealed RN #1 should have used gloves, because she had touched a lot of other things in her treatment cart. The DON stated not using gloves to handle the 4 x 4's could cause cross contamination. On 9/19/19 at 9:56 AM, an interview with RN #2 revealed that RN #1 should have used gloves and not her bare hands, while handling the 4 x 4 gauze dressings, to prevent hand to hand contact with the supplies. She also stated RN #1 could pass germs to the residents by using her bare hands to handle the 4 x 4 gauze dressings. Resident #23 An observation on 09/17/19 at 9:45 AM, revealed RN #1/Wound Care Nurse, entered Resident #23's room, washed and dried her hands, and then turned the faucet off with her clean hand. RN #1 left the room, pulled keys out of her pocket, and opened the wound care cart, then returned the keys to her pocket. RN #1 placed several gauze dressings onto a Styrofoam plate, using her bare hands, then opened the drawer of the wound cart, took out a spray bottle of wound cleanser, wet the gauze, and returned the cleanser to the drawer. RN #1 sanitized her hands, gloved, grabbed the side of Resident #23's geri-chair, and pushed the chair to the side, so she could get to the Resident's stoma. RN #1 pulled up Resident #23's shirt, removed the soiled dressing, and cleaned and dried the resident's stoma. RN #1 pulled the resident's shirt over the stoma between intervals, allowing the shirt to touch the dirty and clean stoma. With gloves on, RN #1 pulled Resident #23's shirt down after applying a new dressing, then, picked up Resident #23's baby doll and handed it to the resident, prior to removing her gloves and washing her hands. An interview on 09/18/19 at 11:50 AM, with RN #1 revealed, I do remember reaching in and getting the gauze with my ungloved hands. It is an infection control issue. RN #1 stated she remembered pulling the shirt back down over the cleaned wound, and stated I mean, what's the point of cleaning the wound if your going to put the shirt back on it. It was contaminated and should have been re-cleaned after the shirt touched it, and before putting a clean dressing on it. I know you probably seen me move the chair with my gloves on, but I don't remember it. I probably did it self-consciously. The wound definitely should have been re-cleaned, prior to putting a clean dressing on. An interview on 09/18/19 at 12:06 PM, with the Director of Nursing (DON), revealed the nurse should not have gotten the gauze with her bare hands, because of cross contamination. The DON stated, If she pulled the shirt back over the wound after cleaning it, and before applying a clean dressing, it was cross contamination also. An interview on 09/19/19 at 9:45 AM, with RN #2, revealed she would possibly consider it an infection control issue with the nurse pulling the shirt back over a cleaned stoma, before applying a clean dressing. She stated she would also consider it a possible infection control issue with the nurse picking up the 4 x 4 gauze with her ungloved hands and placing it onto the plate. She stated, You need a barrier between the clean gauze and your hands. You wouldn't want hand to hand contact with something you're going to use on a resident. You could pass germs to a resident. Record review of a facility document titled, JD-ECF treatment check log Nurse Check off, dated 3/16/16, revealed RN #1 received training in Any cross contamination with treatment. |
2020-09-01 |