| 55 |
BOYINGTON HEALTH AND REHABILITATION |
255092 |
1530 BROAD AVE |
GULFPORT |
MS |
39501 |
2019-03-08 |
880 |
E |
0 |
1 |
M3XR11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, record review, and facility policy review, the facility failed to ensure measures to prevent the possibility of a Urinary Tract Infection [MEDICAL CONDITION] and/or cross contamination during catheter care for Residents #51, for one (1) of six (1 of 6) catheter care observations. The facility also failed to prevent the possible spread of infection and cross contamination during wound care by failure to wash hands during Residents #2, #57, and #133's wound care, for three of six (3 of 6) wound care observations. Findings Include: Review of facility's policy titled, Infection Control Monitoring, dated (MONTH) (YEAR), revealed it is the policy of the center to investigate the cause of infections (nosocomial, community and hospital acquired) and the manner of spread. The records will be maintained and infectious trends or any identified problems or potential problems will be reported to the Administrator, Director of Nurses and the Quality Assurance Committee. Follow up action will be taken as necessary. The objectives of the facilities Infection Control Policies and Practices are to: prevent, identify, report, and control infections and other communicable diseases. Designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Establish guidelines to follow in the implementation of isolation precautions. Maintain records of incidents and corrective actions related to infections. Establish guidelines to follow in implementing standard precautions/universal precautions of the handling of blood/ bodyguards and Antibiotic Stewardship Program. A review of the facility's policy titled, Hand Hygiene dated (MONTH) (YEAR), revealed that it is the policy of this facility handwashing/ hand hygiene shall be regarded by this center as a means of preventing the spread of infections. The policy stated that all personnel shall follow our established handwashing procedures to prevent the spread of infection and disease to other personnel, patients, and visitors. The policy stated that associates must perform appropriate handwashing procedures under the following conditions: before handling clean or soiled dressings, gauze pads, etc., after handling used dressings, after handling items potentially contaminated items with blood, body fluids, excretions, or secretions, and after removing gloves. Review of the facility's policy titled, Catheter Care, Urinary, dated (MONTH) (YEAR), revealed the bag should be held below the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Resident #2 An observation, on 03/06/2019 at 8:46 AM, revealed Resident #2's wound care was provided by Registered Nurse (RN) #3. RN #3 performed the wound care on three (3) separate pressure wounds: a Stage 4 pressure wound to the left (L) Ischium, a Stage 4 pressure wound to the right (R) Ischium, and a Stage 4 pressure wound to the sacral area. RN #3 performed the wound care to both the Stage 4 pressure wounds to the (L) Ischium and the (R) Ischium without incident. During the wound care on the Stage 4 pressure wound to the sacral area, RN #3 discarded the soiled 4X4 gauze used for cleaning the wound, and then continued with the wound care by applying two (2) out of three (3) dressing ropes into the wound bed without washing her hands. After applying the second dressing rope, it was then that RN #3 removed her gloves, washed her hands, put on new gloves, and then continued to apply the third dressing into the wound. During an interview, on 03/07/2019 at 11:00 AM, Registered Nurse (RN) #3 confirmed she did not wash her hands after she discarded the soiled gauze from cleaning the sacral wound, and before she applied the first two (2) medicated rope dressings. RN #3 stated she remembered washing her hands before she applied the third medicated rope dressing. RN #3 stated, I didn't realize I didn't wash my hands, because I usually wash my hands before and after each time I apply the rope dressing into the wound. RN #3 stated that not washing your hands is an infection control concern. During an interview, on 03/07/2019 at 11:15 AM, with the Director of Nursing (DON), the DON revealed RN #3 should have washed her hands after she cleaned the sacral wound, and before she applied the medicated rope dressing. The DON stated, If your hands are not washed, that is an infection control concern. During an interview, on 03/07/2019 at 1:54 PM, with Licensed Practical Nurse (LPN) #1/Care Plan Coordinator, LPN #1 stated that it was her expectation that the nurse would provide the wound care treatment, without risking the possible spread of infection. An interview, on 03/07/2019 at 3:32 PM, with Registered Nurse (RN) #2/Infection Control Nurse, confirmed that during the wound care provided on Resident #2, that RN #3 should have washed her hands after cleaning the wound, and prior to the packing of the wound with rope dressing. Review of the Face Sheet revealed that Resident #2 was admitted by the facility on 03/05/2013, and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #2's Discharge Minimum Data Set (MDS), dated [DATE], revealed a Basic Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Further review of the MDS revealed Resident #2 was coded for the presence of two (2) Stage 3 pressure wounds. Review of Resident #2's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/19/18, revealed a Basic Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Further review of the MDS revealed Resident #2 was coded for two (2) Stage 4 pressure wounds. Resident #57 An observation, on 03/07/19 at 10:15 AM, revealed Registered Nurse (RN) #3/Wound Care Nurse performed wound care to Resident #57's sacrum. Certified Nursing Assistant (CNA) #3 assisted RN #3 with the wound care. RN #3 placed a red bag on Resident #57's bed to the right side of Resident #57's right leg. RN #3 removed the old dressing, and discarded the dressing into the red bag. RN #3 washed her hands, gloved, and began to clean the wound. RN #3 cleaned and patted the wound dry. RN #3 applied Santyl to wound bed with a Q-tip applicator, and covered the wound with a silicone dressing. RN #3 wore the same gloves she had on while cleaning the wound to apply the Santyl and clean dressing to the wound. RN #3 failed to remove her gloves, wash her hands and re-glove after cleaning the wound, and before applying Santyl and the clean dressing to the wound. An interview, on 03/07/19 at 10:48 AM, revealed RN #3/ Wound Care Nurse stated, I knew what I did when I did it. I didn't change gloves and wash my hands after cleaning the wound and before I applied the Santyl and the clean dressing. It could be an infection control issue. An interview, on 03/07/19 at 3:22 PM, revealed RN #2/ Infection Control Nurse stated, RN #3 should have removed her gloves, washed hands and re-gloved before placing the Santyl and bandage on the clean wound. I see that as an infection control issue. An interview, on 03/07/19 at 3:44 PM, with the Director of Nursing (DON) revealed, the nurse not changing her gloves and washing her hands after cleaning the wound and before applying Santyl and the dressing is an infection control issue. Review of Resident #57's Significant Change MDS, with an ARD of 01/11/19, revealed a BIMS score of 10, which indicated moderate cognitive impairment. Further review of the MDS revealed Resident #57 was coded for an unstageable wound. Resident #133 An observation, on 03/05/19, 4:40 PM, revealed Registered Nurse (RN) #3/Wound Care Nurse provided Resident #133's wound care to the right foot/great toe. RN #3 was assisted by Certified Nursing Assistant (CNA) #3. RN #3 set up the wound care supplies on the over bed table, and then she placed the red biohazard bag on Resident #3, which positioned the right toe wound between RN #3 and the red biohazard bag. After looking over the supplies RN #3 identified she forgot to get scissors from the wound care cart. RN #3 left the room, and returned with the scissors in her bare hands. RN #3 laid the scissors on the tray containing her clean dressings without cleaning the scissors. RN #3 removed the dirty dressing, and discarded it into the red biohazard bag. RN #3 washed her hands and gloved to begin cleaning the wound. RN #3 wiped the wound with normal saline soaked gauze, and discarded the gauze into the red bag. RN #3 got another piece of normal saline gauze, wiped the other side of the wound, and discarded the gauze into the red bag. RN #3 took another piece of the normal saline gauze, wiped the wound, and the normal saline dripped down the side of the foot. RN #3 took the same piece of gauze and reached down to catch the dripping saline and wiped back towards the cleaned wound going from an uncleaned area to a cleaned area, thus wiping dirty to clean. RN #3 did not reclean the wound before attempting to apply the wound vac to the wound. RN #3 washed her hands and gloved, and then picked up the foam that was to be packed into the wound and crossed the cleaned wound over to the red bag and held the foam above the red bag, with the dirty dressing and gauze in it, and began trimming the foam with the uncleaned scissors. RN #3 brought the foam from over the red bag back to the wound, and placed it on the wound. She then reached back over and got the second piece of foam and crossed the clean wound again going to the red bag. RN #3 began trimming the foam over the red bag, and then brought the foam back and placed it on wound. She picked up the end of the wound vac that was to be placed over the foam on the wound. RN #3 placed the wound vac tubing on Resident #133's gown. The end to the tubing was uncapped. RN #3 sealed the part of the wound vac with the dressings cut earlier. She then picked up the tubing from the gown and hooked it to the wound vac itself without cleaning the uncapped tube. Suction was obtained. RN #3 cleaned up her trash, washed her hands, and exited the room. An interview, on 03/05/19 at 5:10 PM, with RN #3/Wound Care Nurse revealed, I did wipe the wound from dirty to clean and I knew it when I did it. RN #3 stated, I didn't think about crossing over the wound to the red bag with the foam then bringing it back over and putting it in the wound. I can see where that would be a contamination issue. I cleaned the scissors before bringing them in the room, but I didn't reclean them after bringing them into the room in my hand. I didn't think about that being an issue but I can see where they could be considered dirty being toted in my bare hand. I held the foam above the red bag to trim it, and I wasn't thinking about it being a contamination issue since I didn't touch it. But with the dirty dressing being in the red bag I can see it being a issue. During an interview, on 03/07/19 3:08 PM, RN #2/Infection Control Nurse, revealed wiping the resident's wound from dirty to clean and not recleaning the wound before dressing it would be a infection control issue. RN #2 said RN #3 should not have crossed the leg with the foam to the red bag. RN #2 stated RN #3 shouldn't go across the wound with the wound vac foam because your crossing the clean wound with supplies coming from the over bed table. RN #2 said RN #3 was going back to the clean wound with something dirty after she held it over the red bag. RN #2 also stated the tubing should not have been laid on Resident #133's gown. It should have been on a clean surface or RN #3 should have cleaned it before connecting it to the other capped end of the tube. RN #2 also stated the scissors should have been recleaned before using them since she had transported them in her bare hand. An interview, on 03/07/19 at 3:49 PM, with the Director of Nursing (DON) revealed RN #3's failure not to reclean the scissors before cutting the clean dressing was an infection control issue. The DON stated RN #3 crossing the clean wound with the foam was an infection control issue also. The DON stated RN #3 holding the foam over the red bag to trim it, and then bringing it back to the wound and packing the wound with the foam was an infection control issue. The DON stated RN #3 laying the uncapped tube of the wound vac suction part placed on top of the wound on the resident's gown and not cleaning it before connecting it to the capped end of the actual wound vac was an infection control issue. The DON stated RN #3 should have cleaned her scissors after having them in her hand and before cutting a clean dressing. Review of the Face Sheet revealed Resident #133 was admitted by the facility, on 02/12/19, with the included [DIAGNOSES REDACTED]. Review of Resident #133's Admission MDS, with an ARD of 02/19/19, revealed a BIMS score of 11, which indicated moderate cognitive impairment. Further review of the MDS revealed Resident #133 was coded for a Stage 2 wound. Resident #51 On 3/7/19 at 2:05 PM, an observation revealed Certified Nursing Assistant (CNA) #1 performed Resident #51's catheter care. CNA #1 entered Resident #51's room, applied her gloves, pulled some clean wipes from the container, and began the catheter care. CNA #1 did not wash her hands. CNA #1 wiped around the catheter near the resident's penis three times using one wipe and rotated the wipe as she wiped. She then used another wipe to wipe in a downward motion of the resident's groin areas, using a clean wipe for each side. CNA #1 held the catheter tubing near the meatus, and wiped away from the meatus three times. She then repositioned Resident #51 onto his left side, and cleaned his buttocks, wiping the buttocks areas in a circular and back and forth motion using the same wipe to clean the resident's entire buttocks area. On 03/07/19 at 3:44 PM, an interview with CNA #1 revealed she should have washed her hands before beginning the procedure, and she should have wiped from front to back in an upward motion to prevent the possibility of an infection. An interview, on 03/07/19 at 9:29 AM, revealed Registered Nurse (RN) #7 stated Resident #51 was very independent and did not like for the staff to assist him with anything although he needed it. RN #7 stated he does not think Resident #51 has had any Urinary Tract Infections (UTIs), but he does have spasms. He stated the resident has the catheter because he has some [DIAGNOSES REDACTED] from his [MEDICAL CONDITION]. On 03/07/19 at 3:49 PM, an interview with the Director of Nursing (DON) revealed CNA #1 should have washed her hands so she does not carry anything in to the resident. The DON stated CNA #1 should have wiped in an upward position for infection control purposes. On 03/07/19 at 3:26 PM, an interview with RN #2 revealed, CNA #1 should have washed her hands, gathered her supplies and placed her supplies on a barrier then proceeded to perform her catheter care. RN #2 also stated CNA #1 should have used one wipe to wipe each time in an upward position. Review of Resident #51's most recent comprehensive MDS, with an ARD of 12/19/18, revealed Resident #51 was coded for an indwelling urinary catheter/condom catheter, and not rated for urinary continence. Further review of the MDS revealed a BIMS score of 15, which indicated Resident #51 was cognitively intact. A review of the facility's Face Sheet revealed the facility admitted Resident #51 on 03/13/18 with a [DIAGNOSES REDACTED]. |
2020-09-01 |