cms_SC: 8301
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8301 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2012-05-02 | 490 | L | 0 | 1 | YK4D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Extended, and Complaint Survey, based on observation, record review and interviews, facility administration failed to ensure that policies and procedures were in place/followed to prevent, recognize, and control the onset and spread of infection within the facility. The findings included: On 5-2-12, review of the facility policy entitled Infection Control Committee - Duties and Responsibilities (Revised June, 2010) revealed that The Administrator will be responsible for oversight of the Infection Control Program. During an interview on 5-1-12 at 11:45 AM, the Administrator stated that the Infection Control Committee was not a separate entity but was part of the QAA Committee. He presented an action plan for November 2011 that noted the opportunity for improvement as Proper infection control methods that were in place before are currently not in place. He stated that this was based on general observations of resident care. Steps to correct/improve included: Inservices to be provided to nursing staff by 12-7-11; Compliance rounds to be done daily; and random audits to be done to ensure that infection control procedures were followed. Review of information provided by the facility staff on 5-2-12 revealed that 12 nurses and 1 CNA were inserviced on basic infection control on 11-15-11. Twelve CNAs and two nurses attended an inservice on 11-28-11 on infection control: room set-up/isolation equipment/drawers. Compliance rounds were only documented as completed twice (12-14-11 with 6 residents on isolation, 12-20-11 with 4 residents on isolation). Although additional information regarding completion of the plan and ongoing monitoring/audits were requested, none were provided. Additional inservice records were provided but not all departments/staff were in attendance. There was no evidence that the committee reviewed the implementation of the plan, monitored the outcome, or made needed revisions. During an interview on 5-2-12 at 4 PM, the Administrator stated that he was aware that infection tracking/trending reports were not as accurate as they should be. He stated that he was not personally aware of this but had been advised as a result of a compliance visit by corporate representatives. He stated that the Director of Nurses had not advised him of any concerns. He stated he reviewed them monthly. He stated he had not identified any trends and was unaware of the reporting requirement until the survey. He stated he had no confidence in the recorded data. When asked if infections were discussed in the QAA meeting, he stated no trends had been identified. When questioned related to the implementation of the November 2011 QA plan of action, he stated he was unaware that the inservices had not been completed. When asked for audits and any additional information to verify implementation of the plan, none were provided. The Administrator was unaware that residents had not been placed on transmission based precautions upon onset of signs and symptoms of [MEDICAL CONDITION]. He was also unaware that new residents were admitted to rooms with residents on [MEDICAL CONDITION] precautions (contact). Cross Refer: CFR 483.65 Infection Control F441 The facility failed to notify the physician of the onset of gastrointestinal signs and symptoms of [MEDICAL CONDITIONS] in a timely manner for four of nine sampled residents reviewed with [MEDICAL CONDITION] (Residents #1, #4, #8, #12). Three of these four developed symptoms after admission to the facility (Residents #1, #4, #12). This failure to notify the physician in a timely manner resulted in significant delays in treatment and increased risk/potential for transmission of infection. The facility failed to ensure contact precautions were maintained appropriately for Residents #1, #4, #5, #6, #8, #10. Infection surveillance data was inaccurate/missing for residents who had positive test results for [MEDICAL CONDITION] (Residents #1, #4, #6, #8, #10, and #12). The Infection Preventionist (IP) was unaware of job duties and responsibilities for the infection control program. The facility failed to ensure that surveillance data was reviewed frequently enough to identify, investigate, and address the causes of any trends. Facility staff failed to identify an outbreak of [MEDICAL CONDITION] and notify the local office of the Department of Health and Environmental Control. Procedures were not in place and/or followed to ensure that facility laundry was hygienically cleaned. Procedures were not in place and/or followed to ensure appropriate daily and terminal cleaning of isolation rooms, including those rooms of residents on contact precautions for [MEDICAL CONDITION]. Cross Refer: CFR 483.10(b)(11) Notification of Changes F157 related to facility failure to notify the attending physician in a timely manner of changes in residents' physical conditions which required intervention/changes in treatment. The physician was not notified of the onset of gastrointestinal signs and symptoms of [MEDICAL CONDITIONS] in a timely manner for four of nine sampled residents reviewed with [MEDICAL CONDITION] (Residents #1, #4, #8, #12). Three of these four developed symptoms after admission to the facility (Residents #1, #4, #12). This failure to notify the physician in a timely manner resulted in significant delays in treatment and increased risk/potential for transmission of infection. Cross Refer: CFR 483.75(i) Medical Director F501 related to Medical Director failure to coordinate medical care in the facility to ensure that resident care was consistent with established infection control policies and procedures. Cross Refer: CFR 483.75 Quality Assessment and Assurance F520 related to QAA Committee failure to conduct ongoing reviews of the processes involved in infection control surveillance and monitoring. Staff failed to follow a plan of action established in 11-11 related to ongoing monitoring of compliance with infection control procedures. The immediacy was removed prior to exit from the facility on 5-2-12 after (1) review of the ongoing training content and participation and staff interviews related to that training were conducted, (2) evidence was presented that the medical record audits (with findings) were completed and any notifications/interventions implemented, (3) basic training was provided to the Infection Preventionist related to job duties/responsibilities, (4) the laundry was checked to ensure that it was being hygienically cleaned (5) job desciptions, duties and responsibilities were reviewed with staff members responsible for infection control data collection and analyzation. CFR 483.75 Administration F490 was lowered to a scope and severity of F. | 2016-06-01 |