| 33 |
SANTA FE CARE CENTER |
325030 |
635 HARKLE ROAD |
SANTA FE |
NM |
87505 |
2017-09-21 |
441 |
E |
0 |
1 |
FY1511 |
Based on record review and interview, the facility failed to ensure 1) the staff did proper hand hygiene between residents while performing medication pass in Wing 3, which has the potential to affect all 18 residents residing in the wing (residents were identified by the census list provided by administrator on 09/18/17), and 2) 1 (R #2) of 1 (R #2) (random resident seen going though items on the lunch tables and the trash) resident cleaned her hands after touching used items on dining tables after every meal and after rummaging through garbage bins attached to medication carts, which has the potential to affect all These deficient practices could lead to cross contamination (the process of transferring bacteria or other harmful agents from one surface to another) that could result in illness, debility and death. The findings are: [NAME] On 09/19/17 at 12:13 pm, during observation of the medication pass done by LPN #1, it was observed that LPN #1 administered an insulin injection to R #194, then removed her gloves and wiped her hands with a Prima Guard Adult Cleansing Washcloth (label stated alcohol free). When asked about using the patient care wipes, LPN #1 stated, I am using these today because my little bottle of the waterless hand cleaner has been missing off my cart. I think it is fine (to use the Adult Cleansing Washcloths) and doesn't make my hands so dry. B. On 09/21/17 at 10:49 am, during an interview with the DON (Director of Nurses), he stated, We supply alcohol hand cleanser for the medication carts. Using that (alcohol hand clenser) or washing with soap and water would be appropriate. The adult wipes would not be appropriate. I would say it is possible that there could cross contamination between residents. C. Review of the facility competency form on Handwashing revealed: Washing hands with soap and water is the best way to reduce germs on them. If soap and water are not available, use an alcohol based hand sanitizer that contains at least 60% alcohol. R #2 D. On 09/18/17 at 12:40 pm, during dining observation, R #2 was observed going to tables where all the residents were gone, but the lunch dishes were still on the table. R #2 picked through the plates, rearranged the plates and the meal tickets, and picked up empty baggies and other small items and placed them in her lap. LPN #2, CNA #1 and CNA #2 were present in the dining room; no one attempted tempted to stop her. R #2 moved to another empty table and does the same action; but now had a handful of used paper napkins that she placed in her lap. CNA #1 looks briefly at R #2 and stated That's dirty, (Name of R #2). CNA #1 turned back and talked to another resident. R #2 picks up another empty baggie and puts on her lap. These behaviors were observed again on 09/19/17, 09/20/17, and 09/21/17. The staff did not redirect her not to touch the items on the tables, nor did they attempt to direct her to wash her hands after she had touched the items. E. On 09/21/17 at 9:36 am, R #2 was observed in Wing 1. R #2 had self propelled her wheel chair to the medication cart and opened the attached garbage bin. R #2 rummaged through the contents for few (approximately 3) minutes. The resident then returned to her room. No staff was present in the hall at that time. F. On 09/21/17 at 10:30 am, during an interview, the WCN (Wound Care Nurse) was asked about R #2's behaviors. The nurse explained that this was her normal behavior and that if she was asked not to do this, R #2 gets very upset and become verbally and physically aggressive. She is care planned not to redirect her. When asked about cleaning her hands after this behavior, the WCN stated that they tried to put alcohol based hand sanitizer in her hands and she just made a face at them. When asked about having her wash her hands, the WCN stated that they had not tried this. [NAME] On 09/21/17 at 12:30 pm, during an interview, the DON explained that this was R #2's normal behavior and that if she was asked not to do this, R #2 gets very upset and become verbally and physically aggressive. She is care planned not to redirect her. When asked about cleaning her hands after this behavior, the DON stated that they tried to put alcohol based hand sanitizer in her hands and she just made a face at them. When asked about having her wash her hands, the DON stated that they had not tried this. |
2020-09-01 |