cms_UT: 96
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 96 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2018-06-21 | 880 | E | 0 | 1 | EUNP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, a peripherally inserted central catheter (PICC) site was not clean, dirty trays were placed in the food cart while clean food trays were on the cart, staff touched clothing and equipment then served residents food, and wound care was not clean. Resident identifiers: 9, 17, 28, 93. Findings include: 1. Resident 93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/18/18 at 11:26 AM, Resident 93's PICC dressing was observed to be with wet blood underneath the dressing at the insertion site. The PICC dressing was not dated. On 6/18/18 at 11:35 AM, resident 93 was interviewed. Resident 93 stated her PICC dressing was changed about a week ago, but could not state when it was changed or by whom. A reivew of resident 93's medical record was completed on 6/20/18. Resident 93's admission paperwork revealed that the PICC was placed before admission to the facility on [DATE]. There was no indication in resisdent 93's medical record that the PICC dressing had been changed while the resident had been in the facility from 6/6/18 through 6/20/18. On 6/19/18 at 9:51 AM, a nurses' note documented that the PICC line dressing was clean, dry and intact. On 6/20/18 at 9:32 AM, a second observation was made of resident 93's PICC dressing. The dressing had wet blood under the dressing and approximately one-fourth of the dressing was pulled up, away from her arm. There was no date on the dressing. On 6/20/18 at 10:55 AM, LPN 1 was interviewed. LPN 1 reported that resident 93 had left the facility for a short time, showered at home and returned to the facility about a week ago with her PICC dressing pulling up. LPN 1 stated that she had changed Resident 93's PICC dressing and put the date on a piece of tape on top of the dressing. She reported that there were no doctor's order to change the dressing, but that it should be changed weekly and as needed if it was dirty, soiled, not sealed, or wet. LPN 1 reported that she changed the dressing today because it was pulling up. On 6/20/18 at 11:18 AM, resident 93's PICC dressing was observed to be clean, dry and intact with the date written on the dressing. On 6/20/18 at 3:20 PM, the Director of Nursing (DON) was interviewed. The DON provided documentation that a PICC dressing kit had been sent from the pharmacy and was delivered to the facility. The DON stated that after a resident is admitted to the facility, the PICC dressing should be changed within 24 hours, then every 7 days, or more frequently as needed for problems. The DON was unable to provide documentation that resident 93's PICC dressing was changed. 2. On 6/19/18 at 11:43 AM, CNA 3 was observed to pass hall trays on the South hallway. A food tray was taken in to room [ROOM NUMBER]. CNA 3 brought the tray out of the room approximately 18 minutes later and put it back in the top of the cart. Afterwards, a tray with food was taken out of the cart and taken into room [ROOM NUMBER]. The resident asked for water and was repositioned. The resident stated that he did not want to eat, so the tray was brought out and placed on the cart. The cart was then taken to residents down the East hallway. On 6/20/18 at 1:51 PM, CNA 4 was interviewed. CNA 4 reported that she had worked seven years as a CN[NAME] CNA 4 reported that if she served meals, and the resident refused to eat, she would put the hall tray back in the specific resident's slot on the hall cart. On 6/21/18 at 11:53 AM, the Dietary Manager (DM) was interviewed. She reported that meals returned on the dining cart are thrown away if they go into a resident's room. DM stated that all trays should be delivered clean before picking up dirty trays. 3. On 6/19/18 12:28 PM, CNA 3 was observed feeding two residents in the dining room simultaneously. CNA 3 fed the residents, touched their clothing, touched silverware, wiped one resident's mouth, and continued to feed both residents without hand sanitizing. On 6/20/18 at 1:51 PM, CNA 4 was interviewed. CNA 4 reported that she had worked seven years as a CN[NAME] CNA 4 reported that she performed hand hygiene after leaving each room, when she changed gloves, and before and after meals, along with after using the restroom. CNA 4 reported that when feeding residents in the dining room, if you touch your radio, you must wash your hands. On 6/20/18 at 1:54 PM, CNA 5 was interviewed. CNA 5 reported that she understood hand hygiene must be performed after touching any resident, after wearing gloves, and upon entering and leaving a room. She reported that she washes her hands before feeding residents, after wearing gloves, and after finished feeding them. On 6/20/18 at 2:01 PM, the DON was interviewed. The DON reported that staff should perform hand hygiene while feeding residents if they touch anything else. The DON stated if the resident also touched the silverware, staff should use hand hygiene. 4. Resident 17 was admitted with [DIAGNOSES REDACTED]. Review of the orders for wound care revealed: a. Left 3rd proximal toe ulcer: Cleanse with NS (normal saline), apply very small amount of hydrogel to the wound bed as the primary dressing, cover with moistened saline gauze that is cut to fit the wound bed, oil [MEDICATION NAME] gauze (also cut to fit wound bed), dry 4 X gauze and 1 inch kling. Change daily. b.Left posterior ankle: Cleanse with NS or puracyn plus. Use cutimed sorbact as the primary dressing. Cover with [MEDICATION NAME], kling, and stockinet as the secondary dressing. Change dressing a daily and PRN (as needed). c.Left posterior proximal ankle: Cleanse with NS and puracyn, use cutimed sorbact as the primary dressing, cover with [MEDICATION NAME], kling and stockinet as the secondary dressing. Change daily and PRN. d.Left Anterior lateral lower leg: Cleanse with NS or puracyn. Cover with cutimed sorbact as the primary dressing and then [MEDICATION NAME], kling and stockinet as the secondary dressing. Change daily and PRN. e.Dressing change to left anterior lower leg: Cleanse with NS or puracyn, cutimed sorbact as primary dressing, cover with [MEDICATION NAME], kling and then stockinet as secondray dressing. Change daily PRN f.Left lateral foot ulcer: Clean; dress with non adhesive foam and wrap with kerlix. Change daily Review of the Wound Rounds Assessment on 6/15/18 revealed the following wounds: a. Left third proximal toe, classified as a venous stasis ulcer, measures 4 centimeters (cm) by (X) 1.5 cm X 0.2 cm b. Left anterior lateral lower leg, classified as a venous stasis ulcer, measures 2 cm X 1.3 cm X 0.1 cm c. Left lower leg anterior, classified as a venous stasis ulcer, measures 7.5 cm X 4 cm X 0.2 cm d. Left posterior ankle, classified as a venous stasis ulcer, measures 2 cm X 1.3 cm X 0.1 cm e. Left posterior proximal ankle, classified as a venous stasis ulcer, measures 1 cm X 0.9 cm X 0.1 cm On 6/19/18 at 11:43 AM, resident 17 was interviewed. Resident 17 stated that the reason his wounds were not healing was because of diminished blood flow, and that he was going to have a stent placed on Thursday. Resident 17 stated that the tip of his left toe was not attached to the bone and was only attached by the muscle. Resident 17 stated that the wound now smells and was no longer healing. On 6/19/18 at 1:20 PM Licensed Practical Nurse (LPN) 3 was observed performing resident 17's dressing change. LPN 3 was observed to assembly all necessary supplies for each dressing order and prepare the materials for access during the wound care. LPN 3 was observed to wash her hands and apply clean gloves. LPN 3 then removed all the old dressings and cleansed the wounds with normal saline and guaze. LPN 3 removed her soiled gloves and washed her hands. New gloves were applied and LPN 3 proceeded to perform wound care and apply all new dressings. At 1:50 PM, LPN 1 entered resident 17's room and requested a set of keys from LPN 3. LPN 3 was still in the process of applying new dressings to resident 17's wounds. LPN 3 then reached into her pocket with her right hand, retrieved the keys, and handed them to LPN 1. LPN 3 was then observed to cut a sterile piece of moistened saline gauze and oil [MEDICATION NAME] gauze. The dressing materials were placed on resident 17's left 3rd proximal toe wound bed. A 2 X 2 dry guaze dressing was wrapped around the toe and secured into place. LPN 3's right hand was observed to touch the dressings and resident 17's wound bed. No observation was made of LPN 3 changing her gloves or washing her hands after she handed LPN 1 the keys. On 6/19/18 at 2:00 PM, LPN 3 was interviewed. LPN 3 stated that she tried to reduce cross contamination during the dressing change by educating the resident not to touch the wounds while she was providing wound care. LPN 3 was informed of the observation of cross contamination with touching her keys. LPN 3 stated, Oh, I did do that. I didn't even think about it. 5. Resident 28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 28 was started on hopice services on 11/15/17 and received pressure ulcer wound care. On 6/20/18 at 2:39 PM, LPN 2 was observed performing a dressing change for resident 28. LPN 2 placed the nozzle of the multi-use bottle of wound cleanser on the gauze before cleaning open wound areas. LPN 2 touched her clothing and a marking pen with her gloved hand before she applied two dressings to open areas of skin. 6. Resident 9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/19/18 at 1:25 PM, Certified Nursing Assistants (CNA's) 6 and 7 were observed providing incontinence cares to resident 9. Resident 9 was placed in supine in bed after being transferred from the wheelchair to the bed via a mechanical lift. CNA 7 removed resident 9's urine soak pants and the wet mechanical lift sling and placed the soiled garments at the head of resident 9's bed on the left side. On 6/19/18 at approximately 1:45 PM, CNA 7 was interviewed. CNA 7 stated that the soiled clothing should not have been placed at the head of the bed next to resident 9's head. On 6/19/18 at 1:50 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that soiled linens were to be placed in a bag and not next to resident 9's head. | 2020-09-01 |