| 5254 |
CLAY HEALTH CARE CENTER |
515142 |
1053 CLINIC DRIVE |
IVYDALE |
WV |
25113 |
2015-09-30 |
441 |
E |
0 |
1 |
9ICN11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, infection control log review, staff interview, and Guidelines for the Center for Disease Control and Prevention (CDC), the facility failed to maintain an effective infection control program designed to prevent and control, to the extent possible, the onset and spread of infection within the facility. The facility did not implement appropriate isolation precautions based on the type of infection (herpes [MEDICATION NAME], or shingles), for one (1) of its residents. This had the potential to affect more than a limited number of residents, staff, and visitors. Resident identifier: #10. Facility census: 58. Findings include: a) Resident #10 Review of the infection control log, on 09/29/15 at 3:10 p.m., found Resident #10 was diagnosed with [REDACTED]. Under the column labeled isolation, was the letter N, meaning none. During an interview with the interim director of nursing (DON) at this time, she said the letter N which denoted no isolation, was an error. She provided a copy of physician's orders [REDACTED]. The DON said they moved Resident #10 into a private room on 09/16/15. Upon inquiry as to why they did not utilize airborne precautions, she said although they had no policy or procedure on shingles precautions, they always followed CDC guidelines. She then checked the facility's copy of CDC guidelines and said they called for Airborne and Contact Precautions, rather than just contact precautions alone. Medical record review on 09/29/15 at 3:30 p.m. revealed a physician contact note, dated 09/16/15, which addressed the presence of red blisters to the left side of the resident's face and neck, and starting to appear on the upper chest. The physician ordered [MEDICATION NAME] (an anti-viral medication used to treat shingles), one (1) gram every eight (8) hours for five (5) days. The physician ordered the resident to move into a private room, and for staff to utilize contact precautions. A note dated 09/22/15 addressed the resident returned to the semi-private room in which she formerly resided. The physician discontinued contact precautions. Review of the 2007 CDC guidelines for long-term care found, in part, that shingles could not be spread from one person to another. However, for the resident (or staff person or visitor) who has no immunity to chicken pox, an active case of chicken pox could potentially develop upon contact or inhalation of viral material from an uncovered shingles lesion/eruption. Due to the anatomical location of Resident #10's lesions, not all of her eruptions could be covered, making it impossible to contain all of the viral particles in a dressing. The CDC also included a warning that anyone pregnant either who had no immunity to chicken pox, or who were uncertain of his or her immunity, should not come in contact with an affected person with shingles until after the lesions had dried. Multiple staff interviews offered contradictory reports related to the type of precautions used for Resident #10 when she had active shingles: 1. Nursing Assistant (NA) #48, on 09/29/15 at 4:06 p.m., said Resident #10 had shingles on her neck and shoulders. She said she and other staff wore gowns and gloves when providing care for Resident #10, but not face masks. 2. NA #29, on 09/29/15 at 4:10 p.m., said she provided care for this resident at least one (1) day when the resident had shingles. She said she wore double gloves and a gown, but no facemask. 3. Licensed Practical Nurse (LPN) #20, on 09/29/15 at 4:15 p.m., said she did not enter Resident #10's room when she had shingles because she (LPN #20) gets shingles. She said staff wore gloves and gowns when they entered the resident's private room. She said some wore masks if they desired, but masks were not mandatory for staff and visitors, as the resident was only in contact precautions. 4. NA #12, on 09/29/15 at 4:30 p.m., said she provided care for Resident #10 when the resident had shingles earlier that month. She said she wore a gown and a double pair of gloves when she entered the private room. NA #12 said neither she nor other staff wore masks when in the room, because the resident was only on contact precautions, not airborne precautions. During an interview with the administrator (NHA), on 09/29/15 at 5:00 p.m., she said she was unaware of the need for airborne precautions for shingles. She said the facility did not have a policy and procedure about shingles, but they used the CDC guidelines. She confirmed that according to CDC guidelines, they were to use both contact precautions and airborne precautions. The NHA said she was told the private room was needed for the resident with shingles, and they needed to include masks for staff and visitors. . |
2019-02-01 |