| 23 |
SANTA FE CARE CENTER |
325030 |
635 HARKLE ROAD |
SANTA FE |
NM |
87505 |
2019-07-19 |
880 |
F |
0 |
1 |
W7WU11 |
Based on observation, interview, and record review, the facility failed to ensure 1)that nursing staff followed proper hand hygiene practices while handling linen, 2) failed to ensure staff cleaned and disinfected the glucometer (a machine used to check blood sugar) between residents for with diabetes (a disorder of metabolism), and 3) distribute ice in a sanitary manner. These deficient practices could affect all 98 residents (per matrix provided by the administrator on 07/15/19 and could likely cause cross contamination (transfer of potentially harmful organisms from one resident to another resulting in illness and death). The findings are: Hand Hygiene [NAME] On 07/19/19 at 8:52 AM during observation in the laundry room, Laundry Aid (LA) #1 did not do hand hygiene after she removed her dirty gown and gloves after loading the washer, she then proceeded into the clean dryer room and was observed taking clothing out of the dryer. When ask if she should have done hand hygiene, LA #1 gave a blank stare and looked and her supervisor, who responded for LA #1. The Supervisor stated, Yes, or at least hand sanitizer. B. On 07/19/19 at 10:08 AM during random observation, revealed that Hospitality Aid (HA) #5 was witnessed walking out of R #57's room carrying dirty linen without gloves and opened clean linen closet by her hands and then proceeded to the dirty linen closet and placed linen in dirty linen barrel then went back to the clean linen closet and took out a clean sheet without using any hand hygiene between tasks. C. On 07/19/19 at 10:16 AM during interview, HA #5 was asked if she should be using gloves. She stated, Yes, and was asked when she should she be using hand hygiene. She stated, After handling dirty linen. When asked what the outcome to not using proper hand hygiene, she reported, Cross contamination. D. On 07/19/19 at 10:48 AM during interview, the Infection Control nurse and ADON confirmed that staff should be preforming proper hand hygiene between tasks when handling dirty linen and when working residents. Glucometer Disinfection E. On 07/18/19 at 3:53 PM, during medication pass observation, RN #2 performed a fingerstick blood glucose check on R #70 with a glucometer, then wiped the glucometer with alcohol wipes before returning to the medication cart. F. On 07/19/19 at 3:58 PM, during an interview, RN #2 was asked how she disinfects the glucometer. She stated, I use the alcohol wipes. [NAME] On 07/18/19 at 4:08 PM, during medication pass observation, RN #3 performed a fingerstick blood glucose check on R #202, during the procedure she had to repeat the test and took another glucose test strip out of the vial and laid the vial on the resident's bed. After performing the test, RN #2 returned the glucometer and the vial of test strips into the basket on the medication cart containing supplies to check a blood glucose (lancets, alcohol, test strip vial, glucometer). The glucometer and vial were not cleaned nor disinfected prior to returning them to the supply basket. H. On 07/18/19 at 4:15 PM, during an interview with RN #3, she stated that she disinfects the glucometer at the beginning and end of her shift, but not in between residents. She stated that is what they do at a local hospital where she had worked. I. On 07/18/19 at 4:25 PM, during an interview, the DON was asked about the observed lack of glucometer disinfection. He stated, I teach to use the Saniwipes (a disinfectant wipe) and to disinfect after use between residents. The risk would be infection. [NAME] Record review of the facility policy Blood Sampling-Capillary (Finger Sticks), revised (MONTH) 2014, revealed: Purpose: The purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne disease to residents and employees. Equipment and Supplies: 6. Approved EPA (Environmental Protection Agency) registered disinfectant for cleaning of sampling device. Steps in the Procedure: 8. Following the manufacturer's instructions, clean and disinfect reusable equipment, parts, and/or devices after each use. 11. Replace blood glucose monitoring device in storage area after cleaning. Ice Pass K. On 07/16/19 at 9:29 AM, during observation of the ice pass in Hall #1, CNA #2 was going from room to room with the ice chest on a cart remaining in the hall. CNA #2 would take each pitcher/cup and remove the lid and straw and take the cup to the ice chest. With the ice lid open, CNA #2 would use the scoop to put ice into the pitcher/cup allowing ice to overflow and go back into the ice chest. CNA #2 returned to the room to place the lid and straw back on the cup and then proceed and do the same process for the next resident. She did not perform hand hygiene between the residents although she had handled the cup and straw of the resident. L. On 07/16/19 at 3:17 PM, during observation of the ice pass in Hall #3, CNA #3 was providing ice and water to residents. CNA #3 was going from room to room providing ice from the ice chest on a cart remaining in the hallway. CNA #3 would take each pitcher/cup and remove the lid and straw then take the cup to the ice chest. With the ice lid open, CNA #3 would hold the cup over the ice chest and use the scoop to put ice into each cup allowing ice to overflow from the cup back into the ice chest. CNA then returned to the room to replace lid and straw on the cup and then proceeded with the same process for the next resident. He did not perform hand hygiene between residents although he had handled the cup, lid and straws of the residents. M. On 07/16/19 at 3:21 PM, during observation of the ice pass in Hall #3, CNA #4 was providing ice and water to residents. CNA #4 was going from room to room providing ice from the ice chest on a cart remaining in the hallway. CNA #4 would take each pitcher/cup and remove the lid and straw then take the cup to the ice chest. With the ice lid open CNA #4 would hold the cup over the ice chest and use the scoop to put ice into each cup allowing ice to overflow from the cup back into the ice chest. CNA then returned to the room to replace lid and straw on the cup and then proceeded with the same process for the next resident. She did not perform hand hygiene between residents although she had handled the cup, lid and straws of the residents. N. On 07/19/19 at 10:05 am, during an interview with the IP (Infection Preventionist) about the ice passes, she confirmed that the CNAs should be doing hand hygiene between residents and not allowing ice that touches a resident's cup fall back into the ice chest. She stated, That could cause cross contamination. |
2020-09-01 |