cms_SD: 25
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 25 | AVANTARA HURON | 435020 | 1345 MICHIGAN AVENUE SW | HURON | SD | 57350 | 2019-05-09 | 880 | E | 0 | 1 | L4FS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to: *Ensure appropriate hand washing was done for: -One of two residents (89) wound care observations preformed by wound care nurse I . -Two random residents (18 and 42) during perineal care performed by certified nursing assistants (CNA) K, L, and M. *Provide appropriate catheter care for one of two residents' (144) observed catheter care done by CNAs A and B. *Identify and implement transmission-based precautions for one of one sampled resident (92) to prevent the spread of infection. *Follow cleaning procedure for two of three observed tub cleanings (D and [NAME] wings) by CNAs D and E. *Properly store tub disinfectant chemicals and personal care items in all four tub rooms. *Properly clean mechanical lifts between residents' (51, 78, and 85) use for two of two missed mechanical lift cleaning opportunities done by CNAs M and O. Findings include: 1. Observation and interview on 5/8/19 from 2:52 p.m. through 3:17 p.m. with wound care nurse I regarding resident 89 revealed she: *Had been seeing her since last September. *Stated she had used hand sanitizer when she entered the room. *Assisted repositioning the resident as the pressure ulcer was on her coccyx. *Gloved and took off the resident's soiled dressing. *Took out supplies from her canvas bag. *Measured depth with a Q-tip. -Took her pen out of her bag and wrote down measurements on a paper. *She continued with the same gloves on and cleansed the wound with one 4 x (by)4 sponge and wound cleanser. -Wiped several times over the wound. *Packed her wound with one 2x2 sponge pad, ointment applied with a Q-tip. *Opened and applied a [MEDICATION NAME] dressing to the wound. *Removed her gloves. *Cleaned up the area, threw away garbage, and put supplies in a plastic Ziploc bag in her canvas bag. *Then she put gloves on and pulled up the her pajama pants. *Moved the bed back in place. *Touched the resident's head and neck area and moved her pillow for comfort. *Took off her gloves. *Opened a chocolate kiss and placed it directly into the resident's mouth. *Finished her paperwork using that same pen. *Wiped off the camera, flashlight, pen, and scissors with a sani-cloth wipe. -Sani-cloth wipe instructions were to air dry for three minutes. -Put items directly in her bag. *Applied hand sanitizer to her hands. Interview on 5/8/19 at 3:56 p.m. with wound care nurse I revealed: *It was her practice to use hand sanitizer before and after a procedure. *She did not have to wash her hands with glove changes or before or after a procedure. *She would have followed the policy of her employer. Interview on 5/8/19 at 4:17 p.m. with the director of nursing (DON) concerning the above procedure revealed: *Hand washing would have been expected: -When entering the room. -After removing dressings. -Any time gloves were changed. -After documentation. -Before assisting with a chocolate candy. -She should have followed the nursing homes policy for wound dressing changes. Review of the provider's (MONTH) 2013 Dressings, Dry/Clean policy revealed: *Position resident and adjust clothing. *Wash and dry your hands thoroughly. *Put on clean gloves. *Loosen tape and remove soiled dressing. *Pull glove over dressing and discard into plastic bag. *Wash and dry your hands thoroughly. *Open dressings. *Put on clean gloves. *Assess the wound. *Cleanse the wound using a clean gauze for each cleansing stroke. *Use a dry gauze to pat the wound dry. *Apply the ordered dressing. *Discard disposable items. *Remove your gloves. *Wash and dry your hands thoroughly. *Reposition the bed covers and make the resident comfortable. 2. Observation and interview on 5/7/19 at 11:25 a.m. of CNA M revealed: *She took the standing lift out of resident 85's room and took it to resident 78's room for storage without cleaning it. *It was stored directly over resident 78's bed. *She stated it was not routine to disinfect the lifts when taking them from room-to-room. *That lift was generally stored in resident 78's room. Observation and interview on 5/7/19 at 4:59 p.m. with CNA O revealed she: *Had transferred resident 51 using the standing lift from resident 78's room. *She stated she had taken it back into resident 78's room because she needed more room in resident 51's room. *She had not disinfected the lift. *The lift was placed directly over resident 78's bed. *Both of the above rooms were double rooms and had minimal space. Interview on 5/8/19 at 4:23 p.m. with the DON regarding the cleaning of mechanical lifts between resident use revealed: *The lifts were stored in the residents' rooms that used it the most frequently. *They would need to be wiped off only if they were visibly soiled. Review of the provider's (MONTH) 2013 Cleaning and Disinfection of Resident Care Items and Equipment revealed: *Reusable items were cleaned and disinfected between residents. -That included durable medical equipment. 3. Observation on 5/8/19 at 7:20 a.m. of certified nursing assistants (CNA) A and B during catheter care for resident 144 revealed CNA A: *Washed her hands and set up the necessary equipment at the resident's bedside. *Removed the resident's brief. *Washed her hands, put gloves on, and prepared washcloths with skin cleanser. *With those gloves on she used a washcloth to clean the resident's left and then right groin areas. Using the same washcloth she: -Turned the cloth over and without separating the labia to expose the catheter insertion site she wiped the catheter tubing from the area where the labia and tubing met down the tubing to approximately nine inches below the labia. -Placed that soiled washcloth in a plastic collection bag. She then: *Picked up a clean soapy washcloth. *Performed the perineal care in the same manner washing the left and then right groin, then turning the cloth over and without opening the labia to expose the catheter insertion site, used the same cloth to wipe off the catheter tubing from the labia to approximately nine inches below the labia. *Placed that soiled washcloth in the collection bag. *Picked up a clean soapy washcloth. -Used that washcloth to clean the resident's bottom after CNA B assisted the resident to turn on her side. *Removed her gloves and washed her hands. *Assisted the resident to dress. Interview with the DON on 5/9/19 at 2:09 p.m. regarding the above catheter care observation confirmed the following. She would have expected the CNA to separate the resident's labia and clean around the catheter insertion site for catheter care. Review of the provider's (MONTH) (YEAR) Urinary Catheter Care policy revealed: *The employee was to have washed her hands and put on gloves. *With nondominant hand separate the labia of the female resident. *Maintain the position of this hand throughout the procedure. *Use a washcloth with warm water and soap to clean the labia. Use one area of the washcloth for each downward, cleansing stroke. Next, change the position of the washcloth and cleanse around the urethral meatus. *Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from the insertion site to approximately four inches outward. 4. Observation on 5/17/19 at 11:57 a.m. with CNAs K and L while performing perineal (peri) care for resident 18 revealed: *They brought an EZ lift into the room. *They had not cleaned it.*They washed their hands and put on gloves. *They both removed the brief with soiled loose bowel movement. *CNA L placed the soiled brief into the trash can. *Without removing their gloves CNA K opened the nightstand and retrieved the wet wipes. -Both CNAs rolled the resident to her left side. -CNA K performed peri-care with the wet wipes. -With the same gloves on she held the container to pull a new wet wipe out. -With those same original gloves on both CNAs rolled the resident to her opposite side. *CNA K continued to perform the peri-care. -More wet wipes were removed from the container by CNA K with the same gloves on. *CNA K then removed her gloves and without washing her hands she put on new ones. -She put barrier cream on the resident's bottom. -She removed her gloves and washed her hands. *CNA L then removed her gloves and threw them into the bathroom trash can. -Without washing her hands she took the garbage from the bathroom and placed it near the resident's room door. *Both CNAs assisted hooking the loops of the EZ lift belt to the metal bar of the lift. *CNA K ran the lift controls. *CNA L moved the wheelchair under the resident. -She straightened out the resident's clothes. -She washed her hands. *CNA K left the room with the trash and washed her hands in the utility room. *The EZ lift was removed from the room and was not cleaned appropriately. Interview on 5/18/19 at 4:39 p.m. with the resident care coordinator on [NAME] hall concerning the above care revealed: *She would have expected those CNAs to have washed their hands when coming into a room, leaving a room, and when changing gloves. *The resident was safe. There were opportunities for them to wash their hands. Interview on 5/19/19 at 9:47 a.m. with CNA K regarding the above care revealed: *She should have washed her hands more. *She should have washed her hands after removing her gloves and putting on new ones. *She knew she should have washed her hands when going into a room, in-between removing and putting on new gloves, and when leaving a room. Interview on 5/19/19 at 10:00 a.m. with CNA L regarding the above care revealed: *She should have washed her hands after removing her gloves and putting on new ones. *She knew she should have washed her hands when going into a room, in-between removing and putting on new gloves, and when leaving a room. *It must have slipped her mind. -I usually do wash my hands after removing my gloves. 5. Observation on 5/7/19 at 9:06 a.m. with CNAs K and M while performing care on resident 42 revealed: *There was an EZ stand lift in her room. *The CNAs performed hand hygiene and put on gloves. *With those gloves on they assisted the resident into the EZ stand lift. *They moved her into the bathroom. *Both CNAs helped to lower her pants and wet brief. *With those same gloves on CNA K:-Touched the stand controls and lowered the resident onto the toilet. -Opened the resident's closet and got a brief. *With those same gloves on CNA L took a washcloth, turned on the faucet, and wet and soaped it up. Then she: *Washed the resident's perineal area. *She removed her gloves and put them in the trash bag. -She did not wash her hands. *CNA K removed her gloves and did not wash her hands. *Both CNAs put a new brief on the resident and pulled up her pants. *CNA K used the controls on the EZ lift to raise her from the toilet. -She placed the resident in her recliner. -Then she washed her hands. *The EZ stand was not cleaned prior to removing the lift from the room. Interview on 5/8/19 at 4:28 p.m. with the resident care coordinator on [NAME] hall concerning the above care revealed:*She would have expected them to change gloves after they were soiled or after cleaning the peri-area. *There were opportunities for and I would have hoped they performed hand hygiene. Interview on 5/9/19 at 9:34 a.m. with CNA M concerning the above observation revealed: *She should have changed her gloves.*She should have washed her hands after doing that. Interview on 5/9/19 at 9:49 a.m. with CNA K revealed: *She should have changed her gloves more often and washed her hands each time she removed gloves. *She thought she should have gotten a small bottle of hand sanitizer and carried it with her to use between glove changes. Review of the provider's 7/11/13 Hand washing/Hand Hygiene policy revealed: *Employees must wash their hands for at least fifteen seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: -C. Before and after direct resident contact. -H. Before and after assisting a resident with personal care. -N. Before and after assisting a resident with toileting (hand washing with soap and water). -Q. After contact with a resident's mucous membranes and body fluids or excretions. -U. After removing gloves or aprons. 8. The use of gloves does not replace hand washing/hand hygiene. 6. Review of resident 92's medical record revealed: *[DIAGNOSES REDACTED]. *Interdisciplinary progress notes from 4/29/19 through 5/9/19 revealed no progress notes related to the need for infection control practices, interventions, or infection control education. Review of resident 92's 4/24/19 Minimum Data Set (MDS) assessment revealed his Brief Interview for Mental Status (BIMS) score was twelve indicating moderate cognitive impairment. Review of resident 92's care plan printed on 5/9/19 at 8:30 a.m. revealed there were no goals or interventions related to infection control. Observations on 5/7/19 between 8:15 a.m. and 4:00 p.m., 5/8/19 between 8:00 a.m. and 9:00 a.m., and 5/9/19 between 8:49 a.m. and 11:00 a.m. of resident 92 revealed: *There was a sign outside his room indicating the need for isolation precautions. -Staff were wearing gowns, gloves, and masks when entering his room. *He ate his meals in the dining room and participated in group activities without wearing personal protective equipment (PPE). *He entered and exited his room without performing hand hygiene or using PPE. *He watched television in his room beside his roommate. *There was not a privacy curtain in the room. Interview on 5/7/19 at 5:15 p.m. with registered nurse (RN) J revealed: *She was notified by a physician on 5/3/19 that resident 92's roommate's sputum tested positive for [MEDICAL CONDITION] (MRSA). *Respiratory isolation precautions were started on that date per facility policy for resident 92's roommate. -The use of PPE was started including gowns, gloves, and masks when entering or exiting that room. *The physician was asked at that time about infection control precautions for resident 92 and she was told they were not needed. -There was no documentation to support that information. *The roommate still had a congested, harsh, productive cough but was afebrile. Interview on 5/8/19 at 8:30 a.m. with the resident care coordinator revealed: *She did not know why staff were expected to use PPE in resident 92's room and he was not. *A physician had stated resident 92 was not infected, but there was no documentation to support that information. Interview on 5/9/19 at 10:38 a.m. with the infection control nurse revealed: *Resident 92 was last seen by his physician the end of March. *Resident 92 was educated on the risk of remaining in his room after his roommate tested positive [MEDICAL CONDITION] and was given the choice to move. *She had left a message for a healthcare associated infections specialist for guidance on room placement. *It was her expectation when the nurse was advised that resident 92's roommate tested positive [MEDICAL CONDITION] that room placement recommendations for him was also discussed with the provider. -If there was no provider recommendation the director of nursing and/or the infection control nurse would be notified for guidance. *Resident 92 had been educated on necessary infection control measures. Review of the 7/11/13 Policies and Practices-Infection Control policy revealed: *1. The facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the general public alike. *2. The objectives of our infection control policies and practices are to: -b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public; -c. Establish guidelines for implementing Isolation Precautions, incuding Standard and Transmission-Based Precautions; . Review of the 7/11/13 Isolation-Initiating Transmission-Based Precautions policy revealed: *Policy Statement: Transmission-Based Precautions will be initiated when there is reason to believe that a resident has a communicable infectious disease. Transmission-Based Precautions may include Contact Precautions, Droplet Precautions, or Airborne Precautions. -1. If a resident is suspected of, or identified as having a communicable infectious disease, the Charge Nurse or Nursing Supervisor shall notify the Infection Control Coordinator and the resident's Attending Physician for appropriate Transmission-Based Precautions. Review of the 5/1/13 [MEDICAL CONDITION] (MDRO) policy revealed: *1. Common examples of MDRO's in long term facilities [MEDICAL CONDITION] ([MEDICAL CONDITION]/[MEDICATION NAME]-resistant Staphylococcus aureus) *6. The staff and practitioner will evaluate each individual known or suspected to have infection with a multi-drug resistant organism for room placement and initiation of Contact Precautions on a case-by-case basis. *11. Depending on the situation, placement may include the following: -a. Placement in a room with someone else who is colonized or infected with the same organism, but does not have any other infection (cohorting). -b. Placement with someone who does not have invasive devices or wounds. -c. Placement in a private room, if possible. *17. In general, health visitors and volunteers will be encouraged to wear disposable gowns and gloves during visitation. If refused, visitors will be asked to perform hand hygiene before leaving the room and will be requested to not visit with other residents. Review of the 3/14/16 Isolation-Categories of Transmission-Based Precautions policy revealed: *Contact Precautions: -2. Examples of infections requiring Contact Precautions include but are not limited to: --a. Infections with multi-drug resistant organisms (determined on a case by case basis); -3. Resident Placement --a. Place the resident in a private room if possible. --b. If a private room is not available, the Infection Preventionist will assess various risks associated with other resident placement options (e.g., cohorting, placing with a low risk roommate). -4. Gloves and Handwashing --a. In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, non-sterile) when entering the room. --c. Remove gloves before leaving the room and perform hand hygiene. -5. Gown --a. Wear a disposable gown upon entering the Contact Precautions room or cubicle. *Droplet Precautions: -2. In addition to Standard Precautions, implement Droplet Precautions for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets {larger than 5 microns in size} that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning). -3. Resident Placement: --a. Place the resident in a private room if possible. --b. When a private room is not available, residents with the same infection with the same microorganism but with no other infection may be cohorted. --c. When a private room is not available and cohorting is not achievable, use a curtain and maintain at least 3 feet of space between the infected resident and other residents and visitors. -4. Masks: --a. In addition to Standard Precautions, put on a mask when entering the room or cubicle. Review of the 7/11/13 Infection Control During Visitation policy revealed: *2. Visitation during Transmission-Based Precautions is permitted. Family members and visitors who are providing care or have very close contact with the resident will be trained regarding the use of infection control barriers such as personal protective equipment. 7a. Observation and interview with CNA D on 5/7/19 at 10:51 a.m. in the D wing tub room revealed: *She was cleaning the whirlpool tub after a resident's bath. *She stated staff were expected to follow a whirlpool cleaning procedure posted in the tub room. -It stated whirlpool disinfectant solution was to remain on the tub surface for ten minutes prior to draining and rinsing the tub. *CNA D completed the whirlpool tub cleaning at 11:03 a.m. -The total cleaning time did not allow the disinfectant solution to remain on the tub surface for the required ten minutes per the whirlpool cleaning procedure. b. Observation and interview with CNA [NAME] on 5/9/19 at 9:30 a.m. in the [NAME] wing tub room revealed: *She was cleaning the whirlpool tub after a resident's bath. *She stated staff were expected to follow a whirlpool tub cleaning procedure posted in the tub room. -It stated that stated whirlpool disinfectant solution was to remain on the tub surface for ten minutes prior to draining and rinsing the tub. *She followed that procedure after she completed the last resident's bath of the day. *She did not follow that same procedure in between residents' baths. -She used less time and did not allow the disinfectant solution to remain on the tub surface for the required ten minutes per the whirlpool cleaning procedure. c. Interview on 5/9/19 at 8:45 a.m. with the infection control nurse revealed it was her expectation the whirlpool cleaning procedure posted in each tub room would be followed after each resident's bath. Review of the facility cleaning procedure for Aqua Aire whirlpool posted on the walls of the four tub rooms revealed: 5. Using a scrub brush, thoroughly scrub all interior surfaces of the tub with the solution that remains in the foot well of the tub. You may also use the whirlpool disinfectant spray as needed. Let disinfectant stay on surface for 10 minutes. 8a. Observation on 5/7/19 at 10:51 a.m. in the D wing tub room revealed: *A shelf inside the secured storage cabinet had a permeable plastic tote that held reusable nail clippers and non-reusable nail files of residents' care items. -On that same shelf were whirlpool disinfectant spray and bottles of residents' hair care products including shampoo and conditioner. b. Observation on 5/8/19 at 10:10 a.m. in the C wing tub room revealed: *A shelf inside the secured storage cabinet had a permeable plastic tote that held reusable nail clippers and non-reusable nail files of residents' care items. -On that same shelf were whirlpool disinfectant spray and bottles of residents' hair care products including shampoo and conditioner. c. Observation on 5/8/19 at 3:29 p.m. in the [NAME] wing tub room revealed: *A shelf inside the secured storage cabinet had a permeable plastic tote that held reusable nail clippers and non-reusable nail files of residents' care items. -On that same shelf were whirlpool disinfectant spray and bottles of residents' hair care products including shampoo and conditioner. d. Observation on 5/9/19 at 7:38 a.m. in the A wing tub room revealed: *A shelf inside the secured storage cabinet had two pair of medical scissors and four nail clippers. -The nail clippers had orange colored rust at the point where a nail would be inserted to be cut. *On that same shelf were whirlpool disinfectant spray, boxed cellophane wrap, and bottles of residents' hair care products including shampoo and conditioner. -The shelf was wet when touched. Interview with CNA B at that same time revealed: *The medical scissors were used to remove bandages or gauze from a resident's body. *The cellophane protected residents' skin that was to be kept dry during bathing. *The nail clippers were used for residents' nail care. e. Interview on 5/9/19 at 8:45 a.m. with the infection control nurse revealed there was no specific expectation regarding storage of cleaning chemicals with residents' care items found in the tub rooms. Surveyor: Interview on 5/9/19 at 2:20 p.m. with the director of nursing regarding the above tub room storage areas confirmed disinfectant chemicals were not to have been comingled with personal care items. | 2020-09-01 |