| 36 |
LEXINGTON MANOR SENIOR CARE, LLC |
255091 |
56 ROCKPORT ROAD |
LEXINGTON |
MS |
39095 |
2017-06-28 |
441 |
D |
0 |
1 |
YQ7Y11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and facility policy review, the facility failed to prevent the possible spread of infection as evidenced by failure to wash hands when removing gloves, completing incontinent care without performing hand hygiene upon leaving resident's room, and when disposing of soiled care items in between residents for two (2) of six (6) care observations (Residents #1 and #2) Findings include: Review of the facility's Hand Hygiene Policy, with a revision date of 02/17, revealed staff involved in direct contact with the resident will perform proper hand hygiene procedures to prevent the spread of infection to residents. Hand hygiene refers to either hand washing or the use of an antiseptic hand rub, also known as alcohol based hand rub. The use of gloves does not replace hand hygiene. Wash hands after removing gloves. Antiseptic solution may be applied to hands after proper hand washing. Review of the facility's Hand Hygiene Table, not dated, revealed use either antimicrobial soap and water or alcohol based hand rub between residents, before applying and after removing protective equipment (PPE), including gloves, before and after handling clean or soiled linens, after assistance with personal body functions (elimination), and when in doubt. Observation during incontinent care on Resident #2, on 06/27/17 at 10:25 AM, with Certified Nursing Assistants (CNAs) #3 and #4, revealed CNA #3 removed her gloves after providing incontinent care, left the resident's room and went to the hallway where she obtained clean care supplies and a trash bag from the clean linen cart. CNA #3 took the clean items into Resident #1's room and left them on the night stand. She then went to another resident's room and retrieved a bedside table, then re-entered Resident #1's room to perform incontinent care, all without performing hand hygiene. Observation during incontinent care on Resident #1, on 06/27/17 at 10:40 AM, with CNAs #3 and #4, revealed them completing incontinent care on the resident. Each CNA bagged the soiled items in trash bags and carried them to the trash bins in the hallway. Each CNA lifted the trash can tops, disposed of the soiled bags and re-entered Resident #1's room without performing hand hygiene between residents or after disposing of soiled care items. Staff interview with CNA #3 and #4, on 06/27/17 at 2:30 PM, confirmed they failed to perform hand hygiene after disposing of used care items in the garbage cans in the hallway and prior to re-entering Resident #1's room. CNA #3 confirmed she did not perform hand hygiene after assisting with incontinent care on Resident #2 or before obtaining clean care supplies prior to entering Resident #1's room to perform incontinent care. Staff interview with License Practical Nurse (LPN), Staff Development Nurse/Infection Control Nurse #3, on 06/28/17 at 10:00 AM, confirmed the break in infection control when CNA #3 and #4 failed to perform hand hygiene after they disposed of soiled care items used during incontinent care on Resident #1, and when CNA #3 failed to perform hand hygiene after she assisted CNA #4 with incontinent care on Resident #2, then left the room to obtain clean supplies from the clean linen cart, which she took into Resident #1's room to prepare for incontinent care. LPN #3 stated the most important thing for them to do is wash their hands, especially when in doubt and to always wash their hands when gloves are removed. Interview with the Director of Nursing on 6/26/17 at 11:25 AM, confirmed CNAs should wash their hands when gloves are removed and when entering and exiting the resident's rooms. Review of the facility's face sheet revealed, the facility admitted Resident #1 on 10/25/16. Resident #1's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of the Admission Assessment, dated 04/17/17, revealed Resident #1 had a Brief Interview Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment Review of the facility's face sheet revealed, the facility admitted Resident #2 on 04/08/08. Resident #2's [DIAGNOSES REDACTED].#2 had a BIMS score of 7, indicating the resident had severe cognitive impairment. |
2020-09-01 |