cms_SC: 2274
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2274 | MAGNOLIA MANOR - ROCK HILL | 425165 | 127 MURRAH DR | ROCK HILL | SC | 29732 | 2017-04-21 | 441 | E | 0 | 1 | 9IUY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of both medical records and facility policies, the facility failed to follow procedures to prevent transmission of communicable diseases and infection for one of one resident reviewed on isolation and one of one resident reviewed for tracheostomy. The Findings included: Review of the medical record on 4/21/17 at 3:00 PM revealed Resident #173 was admitted to facility on 4/7/2017 with [DIAGNOSES REDACTED]. Further review revealed that on 4/15/17 Resident #173 was placed on isolation related to Urine Culture results that indicated >100,000 colony-forming units (cfu)/ mL (milliliter) of [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE) During interview on 4/17/17 at 11:03 AM, RN #1 verified that Resident #173 was on contact isolation due to [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE) identified on urine culture results that were received this weekend. Review of Infection Prevention and Control Policy and procedure on 4/20/17 at 10:30 AM revealed that for any resident under Contact Isolation gloves should be worn when having prolonged contact with surfaces in the resident's room that may have a concentration of organisms, such as bedrails, commode chairs, etc. After care rendered, staff should remove gloves before leaving the resident's environment and wash hands immediately with an antimicrobial agent or waterless antiseptic agent, if running water is not available. Observation on 4/20/17 at 8:50 AM revealed C.N.[NAME] #3, C.N.A #4 and LPN #6 in Resident #173's room not wearing any personal protective equipment (PPE). C.N.[NAME] #3 was standing and leaning against bedrail while feeding Resident #173. C.N.[NAME] #3 was then observed leaving Resident #173's room without washing her/his hands and left to enter other resident's rooms. LPN #6 did not don PPE to administer medications to Resident #173. During interview, C.N.[NAME] #3 stated that they only have to dress out when doing care. LPN #6 stated during interview that s/he was aware that Resident #173 was on contact isolation but s/he did not know and had not been told what PPE was supposed to be worn. The facility admitted Resident #161 with [DIAGNOSES REDACTED]. During observation of tracheostomy care and suctioning at 11 AM on 4-19-17, Registered Nurse (RN) #2 failed to follow procedures to ensure prevention of infection. Prior to the procedure, the nurse did not apply personal protective equipment (PPE). During the trach(eostomy) care, RN #2 opened the trach care kit and placed the sterile drape on the overbed table. After opening and placing the sterile disposable inner cannula on the drape, s/he applied sterile gloves. S/he then placed the stoma dressing on the drape and opened and poured Normal Saline into the tray. With the left hand, RN #2 removed the trach collar (humidified oxygen). S/he removed the inner cannula and dressing/drain sponge with the left hand and placed them in the waste receptacle. With the right hand, the nurse wiped the outer cannula/flanges with moist normal saline gauze and used a cotton-tipped applicator with Normal Saline to cleanse around the stoma. During this procedure, s/he secured the tracheostomy with her/his left hand. S/he dried the outer cannula/flanges with gauze. Then, securing the flange with the right hand, the nurse inserted the sterile disposable inner cannula with the left hand. S/he then applied the sterile drain sponge to the stoma site using both hands and replaced the trach collar. The resident began to cough up a large amount of sputum from the tracheostomy. RN #2 obtained 4x4 gauze from the dresser, opened them, and, using both hands, wiped the inside of the trach collar and the outer trach. S/he removed the gloves and checked the resident's oxygen saturation. The nurse then washed her/his hands and prepared to leave the room by removing the plastic bag from the trash can, tying it up, and replacing it with another bag from the bottom of the trash can. The resident started coughing, but was unable to bring up the sputum. RN #2 stated,I'm going to suction. S/he proceeded to wash her/his hands and don non-sterile gloves, but applied no other PPE. S/he turned on the suction machine with her/his left hand and held a non-sterile suction catheter regulator with the right. The suction catheter had been used, was open and on the bedside table. S/he advanced the non-sterile catheter into the tracheostomy twice as the plastic cover pushed back toward the regulator. S/he replaced the humidified oxygen, flushed the suction tubing, placed the suction catheter back in the paper covering on top of the bedside table. S/he did not dispose of the used catheter. The nurse turned off the suction machine, removed her/his gloves, and washed her/his hands. The nurse picked up the trash and proceeded to the soiled utility room. S/he opened the lid to the soiled trash container to dispose of it. RN #2 turned toward the sink, then away, and stated s/he would have to go elsewhere to wash hands because the water does not work. When asked what s/he normally did, the nurse stated s/he would go into the shower room or in the food preparation room to wash her/his hands. S/he proceeded to the food preparation room to wash her/his hands. During an interview on 4-21-17 at approximately 2 PM, the Director of Nurses stated s/he expected the trach procedure to be completed with one hand remaining clean, the other dirty. The facility policy entitled Tracheostomy Care states: 4. Follow relevant infection control procedures as appropriate .12. Aseptically put on sterile gloves, goggles, and gown . The procedure did not address use of a sterile disposable inner cannula. When asked on 4-21-17, the Administrator and Director of Nurses stated that a policy would be submitted for review but none was received. An observation was made on 4-17-17 at 2:20 p.m. of a nebulizer mask on bedside table of Resident #27 that was not covered and the tubing was noted to be touching the floor. This was also observed on 4-18-17 at 12:47 p.m. and on 4-20-17 at 6:50 p.m. It was confirmed during the Environmental Tour on 4-20-17 at 6:50 p.m. with the Maintenance Manager and Head of Housekeeping. | 2020-09-01 |