| 3942 |
STONE PEAR PAVILION |
515130 |
125 FOX LANE |
CHESTER |
WV |
26034 |
2017-01-19 |
441 |
E |
0 |
1 |
E2UQ11 |
Based on observation, medical record review, staff interview, and policy review, the facility failed to maintain an effective infection control program designed to help prevent the development and/or transmission of disease and infection. Residents #58, #5, #4, #64, and #41 had no signage at their doors to caution that those residents were in isolation, or to communicate the type of isolation required, and/or the need to see the nurse prior to entering the room in order to receive specific instructions. An employee was observed going from one room to a second room re-filling residents' ice water pitchers for residents who resided on the East wing, while wearing the same pair of disposable gloves. Although this had the potential to affect any of the residents on the East wing, it most directly affected Residents #25 and #94. A housekeeping employee was observed as she emptied a dust pan into a trashbin next to residents who were eating their lunch. Also, a nurse aide was observed carrying unbagged, dirty linens down the East wing hallway to the soiled utility room. Resident identifiers: #25, #94, #58, #5, #4, #64, #41. Facility census: 52. Findings include: a) Resident #25 Observation on 01/17/17 at 1:35 p.m. found unit nurse aide (NA) #112 passing fresh ice water to residents on the East wing. This wing is currently quarantined because four (4) of their residents on this wing tested positive for type A influenza in the past few days. This employee wore disposable gloves and obtained fresh ice water for Resident #26. Without changing gloves or sanitizing her hands, she then picked up the plastic, pink water pitcher of Resident #25 (room-mate of Resident #26), and brought it out into the hall beside the portable ice chest. Using a metal scoop, she then filled this pitcher with ice. She returned the pitcher to Resident #25. b) Resident #94 Observation on 01/17/17 at 1:35 p.m. found unit aide #112 entered this room to give the resident fresh ice from the ice chest parked in the hallway. This employee wore disposable gloves, but did not change the gloves after having had direct contact with water pitchers which belonged to Residents #25 and #26 who resided together in a room across the hall from Resident #94. Residents #25 and #26 had not tested positive for influenza type [NAME] Employee #112 brought Resident #94's water pitcher out into the hallway by the ice chest, for the purpose of obtaining fresh ice. Upon inquiry as to whether anyone had told her to change gloves between refills of residents' water pitchers, she replied in the negative. She said she now understood that she might pick up an organism from one resident's water pitcher, and transfer it to the ice scoop or the next resident's water pitcher. An interview was completed with the director of nursing on 01/17/17 at 3:30 p.m. She said the employee should have changed gloves between each pitcher refill. She said she will re-educate all staff on this issue. c) Resident #58 Observation on 01/18/17 at 3:15 p.m. found this resident had an isolation cart outside her door. A yellow stop guard with the word stop in red hung across her door. There was no signage to see the nurse before entering, or to communicate the type of isolation that was in place. Review of the medical record found she was in isolation for clostridium difficile, a contagious organism which affects the gastrointestinal tract and causes diarrhea. An interview was conducted with the director of nursing (DON) on 01/18/17 at 3:32 p.m. She said when a resident is in isolation, the nurse places a sign at the resident's door directing visitors and staff to see the nurse before entering. She said they do not post the type of isolation that is in place. She agreed that this resident was in isolation for clostridium difficile. When informed there was no signage at the door to to notify anyone isolation was in place, she said she would check this out. At 5:00 p.m. on 01/18/17, signage was observed posted at the door to see the nurse before entering the room, and the type of isolation for staff to utilize. The DON said this was probably her fault, because she thought the stop sign included to see the nurse before entering. The facility's policy on isolation was provided by the DON on 01/19/17 at 8:00 a.m., and reviewed. Step six (6) stated when transmission-based precautions are implemented, the infection control coordinator or designee shall post the appropriate notice on the room entrance door so that all personnel will be aware of precautions, or be aware that they must first see a nurse to obtain additional information about the situation before entering the room. d) Resident #5 Observation on 01/18/17 at 3:20 p.m. found this resident had an isolation cart outside her door. A yellow stop guard with the word stop in red hung across her door. There was no signage to see the nurse before entering, or to communicate the type of isolation that was in place. Review of the medical record found she was in isolation for clostridium difficile, a contagious organism which affects the gastrointestinal tract and causes diarrhea. An interview was conducted with the director of nursing (DON) on 01/18/17 at 3:32 p.m. She said when a resident is in isolation, the nurse places a sign at the resident's door directing visitors and staff to see the nurse before entering. She said they do not post the type of isolation that is in place. She agreed that this resident was in isolation for clostridium difficile. When informed there was nos signage at the door to notify anyone that isolation was in place, she said she could check this out. At 5:00 p.m. on 01/18/17, signage was observed posted at the door to see the nurse before entering the room,a and the type of isolation for staff to utilize. The DON said this was probably her fault, because she thought the stop sign included to see the nurse before entering. The facility's policy on isolation was provided by the DON on 01/19/17 at 8:00 a.m., and reviewed. Step six (6) stated that when transmission-based precautions are implemented, the infection control coordinator or designee shall post the appropriate notice on the room entrance door so that all personnel will be aware of precautions, or be aware that they must first see a nurse to obtain additional information about the situation before entering the room. e) Resident #4 During an interview with the director of nursing (DON) on 01/18/17 at 3:45 p.m. she showed the line listing of the residents who have tested positive for Type A influenza in the past few days. She said she also shares this information with the county health department. Review of the line listing found that precautions put into place included contact/droplet isolation She agreed there was no signage at the resident's door that directed to see the nurse before entering or to communicate the type of isolation in place, or what garb should be worn while in the room. She said this resident is quarantined to her room until the symptoms subside. She tested positive for Type A influenza on 01/14/17. She said there is posting at the front door of the facility alerting visitors that they have an outbreak of influenza. She said they have boxes of masks and gloves at the nurses' desk that visitors can don. She added that visitors sign in at a log book on the counter of the nurses' station, and write which resident they are visiting. She spoke her belief that some staff would be present at the desk and would inform them if their visited resident was positive for the flu, and that the wing housed residents who were positive for influenza. Observation on 01/18/17 at 5:00 p.m. found the proper signage was now in place at this resident's door. The facility's policy on isolation was provided by the DON on 01/19/17 at 8:00 a.m., and reviewed. Step six (6) stated that when transmission-based precautions are implemented, the infection control coordinator or designee shall post the appropriate notice on the room entrance door so that all personnel will be aware of precautions, or be aware that they must first see a nurse to obtain additional information about the situation before entering the room. f) Resident #64 During an interview with the director of nursing (DON) on 01/18/17 at 3:45 p.m. she showed the line listing of the residents who have tested positive for Type A influenza in the past few days. She said she also shares this information with the county health department. Review of the line listing found that precautions put into place included contact/droplet isolation She agreed there was no signage at the resident's door that directed to see the nurse before entering or to communicate the type of isolation in place, or what garb should be worn while in the room. She said this resident is quarantined to her room until the symptoms subside. She tested positive for Type A influenza on 01/14/17. She said there is posting at the front door of the facility alerting visitors that they have an outbreak of influenza. She said they have boxes of masks and gloves at the nurses' desk that visitors can don. She added that visitors sign in at a log book on the counter of the nurses' station, and write which resident they are visiting. She spoke her belief that some staff would be present at the desk and would inform them if their visited resident was positive for the flu, and that the wing housed residents who were positive for influenza. Observation on 01/18/17 at 5:00 p.m. found the proper signage was now in place at this resident's door. The facility's policy on isolation was provided by the DON on 01/19/17 at 8:00 a.m., and reviewed. Step six (6) stated that when transmission-based precautions are implemented, the infection control coordinator or designee shall post the appropriate notice on the room entrance door so that all personnel will be aware of precautions, or be aware that they must first see a nurse to obtain additional information about the situation before entering the room. g) Resident #41 During an interview with the director of nursing (DON) on 01/18/17 at 3:45 p.m. she showed the line listing of the residents who have tested positive for Type A influenza in the past few days. She said she also shares this information with the county health department. Review of the line listing found that precautions put into place included contact/droplet isolation She agreed there was no signage at the resident's door that directed to see the nurse before entering or to communicate the type of isolation in place, or what garb should be worn while in the room. She said this resident is quarantined to her room until the symptoms subside. She tested positive for Type A influenza on 01/14/17. She said there is posting at the front door of the facility alerting visitors that they have an outbreak of influenza. She said they have boxes of masks and gloves at the nurses' desk that visitors can don. She added that visitors sign in a log book on the counter of the nurses' station, and write which resident they are visiting. She spoke her belief that some staff would be present at the desk and would inform them if their visited resident was positive for the flu, and that the wing housed residents who were positive for influenza. Observation on 01/18/17 at 5:00 p.m. found the proper signage was now in place at this resident's door. The facility's policy on isolation was provided by the DON on 01/19/17 at 8:00 a.m., and reviewed. Step six (6) stated that when transmission-based precautions are implemented, the infection control coordinator or designee shall post the appropriate notice on the room entrance door so that all personnel will be aware of precautions, or be aware that they must first see a nurse to obtain additional information about the situation before entering the room. h) On 01/17/17 at 11:29 a.m., Staff #40 was observed emptying a dustpan in an elevated housekeeping cart next to residents eating a meal. On 01/17/17 at 11:31 a.m. an interview with Staff #40 acknowledged the residents were eating close by and stated that it was the only was the only way she knew how to empty the dustpan after she swept the floor. On 01/17/17 at 11:36 a.m. an interview with Staff #74 acknowledged the unsanitary disposal of dirt and stated that staff know not to empty dust pans near residents who are eating. i) On 01/18/17 at 10:27 a.m. Staff #88 was observed carrying unbagged soiled linen down the hallway. On 01/18/17 at 10:29 a.m. Staff #88 stated that carrying unbagged soiled linen down the hallway was an acceptable practice because the brief was bagged. On 01/18/17 at 10:30 a.m. The DON stated that according to facility policy, as long as staff do not hold the linen against their uniform. Carrying linen down the hallway is acceptable. On 01/18/17 a review of the Laundry and soiled bedding policy was reviewed. The policy does not address the risk reduction measure of potential environmental contamination by having personnel bag or contain contaminated linen at the point of use. This observation occurred on a hall that is under quarantine for influenza. On 01/18/17 at 10:45 a.m. the DON acknowledged that additional environmental infection control measures including having staff bag potentially contaminated linen at point of use are warranted due to the quarantine status. |
2020-04-01 |