| 48 |
BOYINGTON HEALTH AND REHABILITATION |
255092 |
1530 BROAD AVE |
GULFPORT |
MS |
39501 |
2017-01-13 |
441 |
F |
0 |
1 |
QXQE11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review, facility policy review, the facility failed to ensure infection control measures were maintained to prevent the possibility of the spread of infection/contamination during incontinent care for Resident #7 for one (1) of five (5) incontinent care observations, during [MEDICATION NAME] care for Resident #11 for one (1) of three (3) wound care observations, during medication pass for Resident #2 for one (1) of twenty-seven(27) medication administration opportunties observed, and one (1) of two (2) blood glucose fingerstick checks observed, for Resident #2. Findings include: Review of the facility's policy titled, Infection Control Policies/Practices, dated (MONTH) 2014 revealed the primary purpose of the facility's infection control policies and practices are to establish guidelines to follow in providing a safe, sanitary, and comfortable environment, and to aid in preventing the development and transmission of diseases and infections. Review of the facility's policy titled, Care of Facility Property, dated (MONTH) 2014 revealed all equipment used during the course of a shift must be cleaned, and where indicated, disinfected prior to returning to use. Resident #2 An observation of Resident #2's Blood Glucose Fingerstick Check on 1/12/17 at 4:12 PM, revealed Licensed Practical Nurse (LPN) #4 failed to wash her hands prior to the finger stick, and placed the glucometer on Resident #4's bed without a surface barrier. LPN #4 returned to the med cart, and placed the contaminated Glucometer on the medication cart without disinfecting the machine. LPN #4 cleaned the Glucometer with two (2) alcohol prep pads instead of a germicidal/disinfectant wipe. In an interview with LPN #4 on 1/12/17 at 4:25 PM, LPN #4 revealed she had some in-service on infection control practices completed when she was hired four (4) months ago. LPN #4 stated she sometimes cleaned the Glucometer with the Bleach wipes located in the bottom of the medication cart. LPN #4 stated she used hand sanitizer prior to the Glucose check. An observation during medication pass on 1/18/17 at 9:06 AM, revealed Registered Nurse (RN) #6 dropped Resident #2's Intravenous Piggy Back (IVPB) medication (an antibiotic) on the floor, picked it up, and placed it into the medication tray with other medications. RN #6 flushed Resident #2's Saline Lock (SL) with a pre-filled syringe of Normal Saline prior to connecting the IVPB med she previously dropped on the floor, then discarded it (pre-filled syringe of Normal Saline) into the trash container in the room instead of in a SHARPS container. The trash container had a clear trash liner. An interview with RN #6 on 1/13/17 at 10:30 AM, revealed when asked how should she clean off an IVPB med that has touched the floor? RN #6 replied you would clean it off with the (Name Brand) bleach wipes. RN #6 confirmed she dropped the IVPB onto the floor, and then proceeded to hang the medication on Resident #2 without cleaning it. Regarding RN #6 disposing the Normal Saline flush into the trash container, RN #6 stated, I just used it for flush, it's not contaminated with blood. When asked is it ok to dispose of the flush syringe in the regular trash, RN #6 stated the flush was used to flush the saline lock for Resident #2. Review of the facility's Face Sheet revealed the facility admitted Resident #2 on 6/4/16 with the [DIAGNOSES REDACTED]. Record review of Resident #2's quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 12/23/16 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of two (2) that indicated Resident #2 was severely cognitively impaired. Resident #11 An observation on 1/12/17 at 10:10 AM, revealed LPN #2 provided [MEDICATION NAME] care for Resident #11. LPN #2 did not place a barrier cover over Resident #11's overbed table. LPN #2 placed the following items onto the overbed table: 1 (one) container of [MEDICATION NAME] solution, 1 (one)package of gauze dressing, 7 (seven) plastic vials of normal saline solution, 1 (one) roll of paper tape, and vinyl gloves. LPN #2 removed a pair of bandage scissors from her pocket, and cut the [MEDICATION NAME] stoma bag opening, placed the scissors on the table without cleaning them, and then picked up the scissors and placed them back into her uniform pocket. After completing the [MEDICATION NAME] care, LPN #2 placed the above [MEDICATION NAME] care items onto the resident's dresser in his room. The roll of paper tape was left on the overbed table. LPN #2 did not disinfect the overbed table before she left the resident's room. Interview on 01/12/2017 at 4:45 PM, with LPN #2 revealed she did not clean the bandage scissors, and they should have been stored in a bag. LPN #2 stated, I know now not to put them in my pocket. LPN #2 confirmed she should have used a drape, and cleaned the overbed table with blue top wipes. LPN #2 stated she did not clean her scissors, and the overbed table because she was in a hurry. Review of LPN #2's Orientation In-Service Acknowledgement record dated 04/04/2016 revealed LPN #2's initials were documented for Prevention/Infection Control. Review of the facility's In-Service Training Attendance Record titled, Infection Control, review of policy, review of practices related to resident care, med pass, isolation, and handwashing, dated 11/28 to 11/29/16, revealed LPN #2's initials were documented on the Sign In Sheet. Review of the facility's Face Sheet revealed the facility admitted Resident #11 on 06/01/2016, and readmitted him on 09/07/2016. Resident #11's [DIAGNOSES REDACTED]. Review of Resident #11's Minimum Data Set with and Assessment Reference Date of 12/12/2016 revealed Resident #11 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated he had no cognitive impairment. Review of Section H for Urinary Continence revealed the resident had a urinary ostomy. Section I for Active [DIAGNOSES REDACTED]. Resident #7 An observation on 01/13/17 at 11:00 AM, revealed Certified Nursing Assistant (CNA) #1 performed incontinent care on Resident #7. After completing the care, CNA #1 did not remove the soiled gloves, and touched Resident #7's clean brief and incontinent pad that was placed under the resident. An interview on 01/13/17 at 11:20 AM, revealed CNA #1 stated, I forgot to take my gloves off before putting on the clean brief and pad. CNA #1 stated, That was an infection control break. An interview on 01/13/17 at 12:40 PM, with the Director of Nursing (DON) revealed the training with the CNAs covered infection control during peri-care. The DON stated the gloves should have been changed from soiled to clean areas. A review of CNA #1's Skills Check: Perineal care-Male Resident, dated 11/18/16, revealed steps to remove gloves after care and before repositioning resident, and a checkmark was placed beside this step marked as completed correctly. A review of the facility's Face Sheet revealed the facility admitted Resident #7 on 10/14/15. Resident #7's [DIAGNOSES REDACTED]. A review of Resident #7's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/05/16 revealed Resident 7's Brief Interview for Mental Status (BIMS) score was conducted per staff interview, and was a three (3), which indicated severe cognitive impairment. |
2020-09-01 |