cms_AZ: 56
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 56 | HANDMAKER HOME FOR THE AGING | 35016 | 2221 NORTH ROSEMONT BOULEVARD | TUCSON | AZ | 85712 | 2016-10-06 | 441 | D | 0 | 1 | VEV011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and review of policies and procedures, the facility failed to ensure that dietary staff used proper handwashing techniques and failed to ensure proper infection control practices were implemented during a pressure ulcer treatment for one resident (#24). Findings include: -Observations were conducted on (MONTH) 5, (YEAR) of multiple dietary staff members washing their hands in the kitchen sinks. The handwashing sinks were equipped with faucet rods in the center of the faucet spigot. The purpose of the faucet rods were to turn the water on and off. To turn on the water, the faucet rod had to be moved and the rod had to be held onto, in order to keep the water flowing. If you let go of the rod, the water turned off. Multiple observations revealed that dietary staff touched the faucet rods with their soiled hands to turn on the water, then let go of the faucet rod and lathered their hands with soap, then they had to touch the faucet rod again with their clean hands to start the flow of water, in order to rinse their hands. An interview was conducted with the dietician (staff #233) on (MONTH) 5, (YEAR) at 11:20 a.m. The dietician stated that the faucet rod was contaminated, unless it was facility procedure to clean the faucet rods after each use. An interview was conducted with the food service assistant manager (staff #63) on (MONTH) 5, (YEAR) at 12:00 p.m. The food service assistant manager did not recognize a problem with this handwashing procedure. A review of the facility's policy on Hand Washing revealed for staff to wash hands following proper hand washing procedures. Instructions on how to wash hands included to turn on the faucet using a paper towel to avoid contaminating the faucet, wet hands and scrub with soap and additional water as needed, rinse thoroughly, dry hands with a paper towel and turn the faucet off with a paper towel. -Resident #24 was readmitted on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. A review of the clinical record revealed documentation that the resident had an unstageable pressure ulcer on the left heel A pressure ulcer treatment observation was conducted on (MONTH) 4, (YEAR) at 1:15 p.m., with a RN (registered nurse/staff #222). At this time, staff #222 was observed to gather the treatment supplies, enter the resident's room, donn gloves and place all of the treatment supplies, including a tube of Santyl and various dressings, on the resident's bedside table. However, staff #222 was not observed to wash or disinfect her hands prior to this. A clean barrier also had not been placed on the bedside table. Staff #22 then raised the head of the resident's bed and changed her gloves. Staff #222 then removed the old dressing and changed her gloves. However, staff #222 was not observed to wash or disinfect her hands after the removal of the soiled dressing. Staff #222 then proceeded to wash the pressure ulcer with soap and water, measured the wound, removed her gloves and washed her hands. However, she was only observed to rinse her hands under the water for five seconds and did not use any soap. She then touched the automatic paper towel dispenser twice, with her clean hands, thereby, coming into contact with a potentially contaminated surface (the paper towel dispenser). Once her hands were dry, staff #222 was observed to donn gloves and apply the Santyl ointment with her gloved finger to the pressure ulcer and then placed a dressing on the wound. An interview was conducted on (MONTH) 4, (YEAR) at 2:15 p.m., with staff #222. She stated that she had washed her hands prior to gathering the treatment supplies, but agreed that she had not washed her hands prior to donning gloves at the start of the treatment. Staff #222 also stated that she should have cleaned the bedside table surface or placed a barrier on it. In regards to handwashing, staff #222 stated that she should have washed her hands every time she changed her gloves and that she should have washed her hands with soap and water for 30 seconds. An interview was conducted on (MONTH) 4, (YEAR) with the DON (Director of Nursing/staff #161), who stated that the RN should have washed or disinfected her hands, prior to the start of the pressure ulcer treatment and should have washed her hands with soap and water for 30 seconds, and she should not have touched the paper towel dispenser with her hands after washing. Staff #161 also stated that the resident's bedside table should have been wiped down or a paper towel placed on it, in order to provide a clean work surface. A facility policy titled, Handwashing/Hand Hygiene included This facility considers hand hygiene the primary means to prevent the spread of infections. The policy also included the following: 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: b. Before and after direct contact with residents; g. Before handling clean or soiled dressings, gauze pads, etc; j. After contact with blood or bodily fluids; k. After handling used dressings, contaminated equipment, etc. m. After removing gloves; 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. In addition, the policy included a section for proper hand washing. It included the following: 1. Vigorously lather hands with soap and rub together creating friction to all surfaces for a minimum of 20 seconds (or longer) under a moderate stream of running water, at a comfortable temperature. The handwashing/hand hygiene policy also included a section titled, Applying and Removing Gloves and the following was included: 1. Perform hand hygiene before applying non-sterile gloves. | 2020-09-01 |