| 83 |
THE PILLARS OF BILOXI |
255093 |
2279 ATKINSON ROAD |
BILOXI |
MS |
39531 |
2017-03-10 |
441 |
D |
0 |
1 |
U1S311 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure infection control measures for the potential spread of infection were followed as evidenced by staff using gloves stored in uniform pockets to provide resident care, staff failure to change gloves, failure to dispose of medical waste, disinfect resident care equipment after use, and placing a nebulizer treatment on the floor during resident care. These deficient practices effected three of nine (3 of 9) residents observed during the med pass, Resident #15, Unsampled Residents J and K; one (1) of six (6) residents observed for Foley catheter care, Resident #6, one (1) of 102 resident rooms observed during the initial tour. Findings include: Review of the facility's policy titled, Gloves, dated (MONTH) 1, 2000, revealed hands should be washed immediately after removing gloves. Review of the facility's policy titled, Handwashing, dated (MONTH) 1, 2000, revealed personnel wash their hands to prevent the spread of infection and disease to other residents. Review of the facility's policy titled, Cleaning/Disinfection of Resident Care Items and Equipment, dated (MONTH) 15, 2010, revealed non-critical items were those in contact with intact skin and could be decontaminated when they are used. Review of the facility's policy titled, Intravenous Fluids (IV), Administration of, revealed: Infection Control: 6. Dispose of disposable equipment appropriately, 7. Dispose of hazardous materials appropriately. Resident #15 An observation during med pass on 03/08/17 at 9:10 AM, revealed License Practical Nurse (LPN) #4 performed a nebulizer treatment for [REDACTED]. LPN #4 dropped the intact plastic three (3) milliliter vial on the floor, then picked the vial up off the floor to use for the nebulizer treatment. LPN #4 placed the nebulizer machine on the floor beside the bed, and attached the nebulizer mask and tubing to the machine. LPN #4 told the resident, I will set this down here because it makes so much noise. LPN #4 put the medication into the nebulizer vial while the machine and the tubing were still on the floor. LPN #4 then picked up the machine, and placed it on overbed table while it was running, but did not disinfect the machine, or place a barrier on the table. An interview on 03/08/17 at 9:15 AM, revealed LPN #4 confirmed he did set the nebulizer machine on the floor. LPN #4 said he usually set the machine on the bedside table, but it shook, and made noise, and would slide off. An interview on 03/10/17 at 9:10 AM, with the Director of Nursing (DON) revealed the nurse should have set the nebulizer machine on the bedside table. The DON said the concern was the spread of infection. The DON said the pharmacists randomly selected nurses to observe during medication pass every month, and the pharmacist only reports to her if he had any problems. A review of a facility's In-Service dated 06/01/16, revealed to place a barrier down when setting anything down in the room. Unsampled Resident J An observation during med pass on 03/08/17 at 9:20 AM, revealed Registered Nurse (RN) #3 donned gloves, and applied two skin patches, an [MEDICATION NAME] and a [MEDICATION NAME], to Unsampled Resident J's skin. RN #3 removed her gloves, but did not wash or sanitize her hands before she typed on the computer keyboard on top of the medication cart. RN #3 then removed the pulse oximeter from her scrub top pocket, and placed it on top of the medication cart without disinfecting the device. Unsampled Resident K An observation on 03/08/17 at 12:25 PM, during med pass, revealed RN #3 donned gloves she had placed in her scrub top pocket. RN #3 mixed the Vancomyacin IVPB (Intravenous Piggy Back) medication, disinfected the top of the PICC (Peripheral Inserted Central Catheter) line, flushed the PICC line with Normal Saline, connected the IVPB tubing to the PICC line, and started the infusion via a IV (Intravenous) pump. RN #3 wore the same gloves she removed from her uniform pocket during the entire IV med set up and administration observation. An interview on 03/08/17 at 12:40 PM, revealed RN #3 confirmed she had used her pockets to store gloves and the pulse oximeter, and she nromallty did use her pockets to store her gloves. RN #3 said the concern was the spread of infection. An interview on 03/10/17 at 9:10 AM, revealed the DON said the gloves and the pulse oximeter should not be stored in uniform pockets. A review of a Medication Administration Observation dated 03/01/17, revealed RN #3 was observed by the pharmacist during medication pass. A review of the facility's Education In-Service Record-Medication Pass, dated 08/25/16 and 08/26/17, revealed nurses should wash hands before and after direct resident care. A review of the facility's Face Sheet revealed the facility admitted Resident #15 on 09/20/16. Resident #15's [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/16, revealed Resident 15's Brief Interview for Mental Status (BIMS) was 14, which indicated intact cognitive status. Resident #6 Observation on 03/08/17 at 3:25 PM, revealed Certified Nursing Assistant (CNA #1) provided incontinent care for Resident #6. CNA #1 pulled gloves from her uniform pockets, and donned the gloves. CNA #1 began, and completed Resident #6's incontinent care using the gloves from her uniform pocket. Interview on 03/08/17 at 4:20 PM, revealed CNA #1 confirmed she removed gloves from her uniform pocket while performing Resident #6's incontinent care. CNA #1 stated, I've always done that. I didn't know. Interview on 03/08/17 at 4:30 PM, with CNA #2, revealed gloves are not clean anymore when placed inside your pockets. Interview on 03/09/17 at 9:30 AM, revealed CNA #3 confirmed she witnessed CNA #1 pulling gloves from her pocket. CNA #3 stated using contaminated gloves could cause the spread of infection. Interview on 03/08/17 at 4:15 PM, revealed Registered Nurse (RN) #1 stated when asked if staff should store gloves in their uniform pockets, Not that I'm aware of. A review of the Face Sheet revealed the facility admitted Resident #6 on 02/01/17, with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/08/17, revealed Resident #6 did not fully complete the Brief Interview for Mental Status (BIMS). Per staff interview, Resident #6 had moderate impaired cognitive skills. One (1) of 102 Resident Rooms Observations, and interviews during the initial tour on the Memory Care Unit with Registered Nurse (RN) #6, on 3/7/17 from 11:00 AM to 12:20 PM, revealed in room [ROOM NUMBER] A, an empty intravenous piggy back (IVPB) medication bag was on the back of the toilet. The medication bag label revealed the IVPB was an antibiotic for (Name of Resident) in room [ROOM NUMBER] [NAME] RN #6 stated at this time the IVPB bag should be in a biohazard container because it was an IV. On 03/8/17 at 1:34 PM, an interview with the Director of Nursing (DON) revealed the IV bag would be hazardous waste, and should have had the label removed, put in a red bag, and disposed of as medical waste. It should not have been left in the resident's bathroom. |
2020-09-01 |