cms_WV: 186
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 186 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2018-09-27 | 880 | E | 0 | 1 | DL7D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interview the facility failed to maintain an effective infection control program designed to provide a safe and sanitary environment to help prevent the development of and transmission of communicable disease to the extent possible. A nursing assistant provided care to Resident #101 who was in contact precautions, without donning a gown or gloves. Licensed nurses cleaned the facility's two (2) resident shared glucometers improperly using 70% ethyl alcohol. One facility staff member was observed utilizing an improper hand-washing technique. The facility also failed to handle, store, and/or process linens in a satisfactory manner to prevent infection. These practices had the potential to affect more than a limited number of residents. Resident identifier: #101. Facility census: 52. Findings included: a) Resident #101 Observation on 09/24/18 at lunch time found nursing assistant employee #32 (E#32) entered the room of Resident #101 to deliver his lunch tray. A sign on the door conveyed that he was in contact precautions. An isolation cart sat outside his door in the hallway. E#32 did not don an isolation gown or gloves. She touched his bed linens with her bare hands. She touched his overbed tray with her bare hands. She picked up the bed control with her bare heads and raised the head of his bed. She helped him become positioned comfortably, and removed the brown plastic lid which covered the hot foods on his plate. At 12:19 PM E#32 walked down the hallway to the dining room where she passed this brown plastic plate cover through the kitchen window, where she placed it on top of other plate covers. She then used hand sanitizer and left the dining room. Review of the medical record on 09/25/18 found a physicians order dated 09/21/18 for contact isolation due to [MEDICAL CONDITION] resistant [DIAGNOSES REDACTED] aureus (MRSA) of the right foot wound. An interview was conducted with infection control registered nurse employee #11 (E#11) on 09/27/18 at 9:30 AM. When presented with the afore mentioned scenario, she said that staff should have gowned and gloved if they touched his bed. She said the lab faxed wound culture and gram stain results to them late in the day on 09/24/18. She said those results were negative. She provided a copy of a physician's orders [REDACTED]. This order was written, signed, and dated as 09/24/18 at 4:00 PM. She acknowledged that he was still in contact precautions at noon on 09/24/18 when observed. On 09/27/18 at 1:15 PM an interview was conducted with the administrator and the assistant administrator. They acknowledged this infection control infraction. No further evidence was provided prior to exit. b) Resident shared glucometers An interview was conducted with licensed nurse employee #47 (E#47) on 09/27/18 at 10:45 AM. She was asked when she cleans the glucometer and how she cleans it. She said she cleans the glucometer used for residents on her end of the hall with a 70% alcohol swab after each patient use. An interview was conducted with licensed nurse employee #25 (E#25) on 09/27/18 at 10:50 AM. She was asked when she cleans the glucometer and how she cleans it. She said she cleans the glucometer used for residents on her end of the hall with a 70% alcohol swab after each patient use. At 11:00 AM on 09/27/18 an interview was conducted with the director of nursing (DON). She provided a policy titled Glucometer Disinfection with revision date 08/27/18. Their policy directed that the facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. It further stated that the glucometers should be disinfected with a wipe pre-saturated with an EPA (Environmental Protection Agency) registered healthcare disinfectant that is effective [MEDICAL CONDITION](human immunodeficiency virus), [MEDICAL CONDITION] and [MEDICAL CONDITION] virus. The DON produced a canister of Sani-Cloth wipes. She said that staff must use these Sani-Cloth wipes to clean and disinfect the glucometers after each use. She said that 70% alcohol was not acceptable. The label on this canister of Sani-Cloth wipes conveyed this product was a germicidal disposable wipe that was bactericidal, tuberculocidal, and virucidal in two (2) minutes. The label contained a statement that the wipes are effective against bacteria, multi-drug resistant bacteria, viruses, bloodborne pathogens, and pathogenic fungi. An interview was conducted with the administrator and the assistant administrator on 09/27/18 at 1:15 PM. They acknowledged their understanding of this issue. At 2:00 PM on 09/27/18, the assistant administrator provided a list of names of nine (9) residents in the facility who receive accu-checks at least daily. c) During observation of laundry pick up on 09/26/18 at 9:16, Laundry Supervisor (LS) #72 wore the same gloves throughout pick-up of all soiled linens on A wing unit, and while gathering soiled linens from various resident's rooms. LS #72 removed gloves after transferring all the soiled linen bags into the laundry shoot from linen cart. LS #72 did not wash her hands after removing gloves before initiating the next task. Compliance guidelines within the facility's hand washing policy state that all facility personnel must wash their hands for twenty seconds using the appropriate technique after handling soiled dressings, linens, contaminated equipment, and after removing gloves. LS #72 failed to utilize proper hand hygiene to prevent the spread of infection during observation on 09/26/18 at 9:40 AM. LS #72 was observed washing hands with soap and water, turning off water facet with clean hands, then drying hands with paper towels, therefore re-contaminating hands. Facility policy for Hand Washing states that proper hand washing technique is: Use water to wet hands. Apply soap. Rub hands and clean between fingers briskly for 20 seconds. Rinse under warm water. Towel dry with clean disposable towels. Turn off faucet with clean paper towels. d) The facility failed to handle, store, process, and transport linens so as to prevent the spread of infection. Observation of the laundry room on 09/26/18 at 9:22 AM, in the presence of the Laundry Supervisor (LS) #42 reveled the following: No separation between the soiled and clean linen areas. No identified negative airflow from the clean to soiled areas. During this observation LS #42 acknowledged the laundry room lacked separation between the clean and soiled areas and noted she was not aware negative air flow was needed, they were told to crack a window while air conditioning unit was on. LS #42 did not wear any protective barrier, such as apron or disposable gown, while handling soiled or clean linens, while allowing linens to touch her uniform and stated, Dirty laundry is always in a linen bag when they are sent down the laundry shoot, so we don't contaminate the area. LS #42 was observed at 9:30 AM on 09/23/18 removing a clean resident privacy curtain from the washer, allowing the linen to touch the floor and her uniform, then hanging the clean linen on a clothes line in the laundry room after the clean linen came into contact with staff's contaminated uniform. Review of facility policy for handling soiled linen state linen should not be allowed to touch the uniform and floor and should be handled as little as possible, with minimum agitation to avoid contamination of air, surfaces, and person. On 09/26/18 at 11:00 AM informed Assistant Administrator(AA) #13 of infection control issues with laundry and asked for policy on soiled linen, AA #13 advised she was unaware of requirements for laundry area environment requirement of separation of clean and soiled area and have never been cited for an issue. | 2020-09-01 |