cms_WV: 5614
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5614 | MONTGOMERY GENERAL HOSPITAL | 515081 | 401 6TH AVENUE | MONTGOMERY | WV | 25136 | 2015-03-04 | 314 | D | 0 | 1 | KF9N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Staff failed to identify and treat a pressure ulcer of a resident on admission to the facility, and failed to properly utilize a specialty mattress, and utilized improper technique during wound dressing changes. Resident identifier: #3 and #5. Facility census: 38. Findings include: a) Resident #3 A closed record review, on 02/26/15 at 10:19 a.m., revealed a hospital discharge summary and pre-admission assessment, each dated 09/16/14, indicating Resident #3 was transferred to the extended care unit with a Stage III sacral pressure ulcer. The nursing admission note, dated 09/16/15, and nursing assessment, dated 09/17/14, did not address a sacral pressure ulcer. The nursing note indicated a dressing was present on Resident #3's sacral area, but did not indicate it was removed for assessment. The director of nursing (DON), interviewed on 03/04/15 at 9:35 a.m., reviewed the medical record and confirmed no evidence was present to indicate staff assessed Resident #3's wounds, and confirmed no evidence was present to indicate the wound dressings were removed to assess the sacral wound on admission to the facility. She acknowledged the facility failed to assess Resident #3's sacral wound until 09/29/14, at which time the facility obtained an order for [REDACTED].>b) Resident #5 1) On 02/26/2015 at 11:09 a.m., Licensed Practical Nurse (LPN) #28, assisted by Nurse Aide (NA) #42, completed a dressing change of Resident #5's sacral pressure ulcer. Resident #5 was lying on his back on an air fluidized bed with two (2) large cloth incontinence pads beneath him. (Note: The incontinence pads inhibit the desired effects of the air fluidized bed.) Nurse Aide (NA) #42 assisted the nurse to position Resident #5 on his right side. The LPN removed a dressing from Resident #5's right buttock and a dressing from the left buttock while wearing the same gloves. Neither dressing covered a visible wound. While wearing the same gloves used to remove the two (2) dressings from the resident's buttocks, which rendered the gloves contaminated, the nurse cleaned around the top and outer aspects of an open wound on the resident's coccyx/sacral area. This open area did not have a dressing prior to the beginning of this treatment. She then wiped through the wound bed, from the coccyx toward the anus, with the same gauze used to clean around the top and outer wound bed. This created a potential for spreading microorganisms from the dressings on the buttocks as well as the periphery of the open wound. Upon completion of the wound treatment, the nurse placed a small coccyx/sacral dressing, which did not completely cover the bottom of the wound bed. 2) During a second observation, on 03/02/15 at 3:24 p.m., LPN #36 set up the dressing tray, donned gloves, assisted NA #63 position Resident #5 on his left side, removed her gloves and utilized hand sanitizer for a count of five (5) seconds. The nurse removed the dressing from the resident's coccyx area, revealing an elongated open area. LPN #36 cleansed the wound bed, removed the soiled gloves, and utilized hand sanitizer, scrubbing her hands for four (4) seconds, donned new gloves, and completed the treatment. After completing the coccyx treatment, LPN #36 and NA #63 repositioned Resident #5 on his back. The NA placed her hands beneath the resident's leg and raised it for the nurse to change the dressing. The LPN utilized hand sanitizer for about five (5) seconds, donned new gloves, and removed the soiled dressing from the pressure ulcer on the posterior aspect of the right calf. The LPN removed her soiled gloves, again utilized hand sanitizer for a count of four (4) seconds, and then donned new gloves. LPN #36 cleansed the wound bed wiping from the center of the wound bed to the outside of the wound, then wiped the center of the wound again, utilizing the same four by four (4 x 4) gauze pad. The nurse left the gauze pad on the resident's wound-bed, soiled with bright red blood. With nothing to hold it in place, the gauze fell on to the mattress. Without changing gloves, Employee #36 applied a new dressing and wrapped the wound with Kling. She removed her gloves. She did not utilize hand sanitizer, or wash her hands. Upon completion of the right leg treatment, NA #63 raised Resident #5's left lower leg. LPN #36 obtained gloves, then put hand sanitizer on her hands. The nurse attempted to sanitize her hands while holding the gloves in her hands. The nurse then donned the gloves she had held in her hands while using the hand sanitizer, and removed the soiled dressing from the posterior aspect of the resident's left lower leg calf area. She opened the bottle of saline while wearing the soiled gloves and poured it over a package of individually wrapped gauze dressings. Without changing gloves she applied a new treatment and covered the dressing. While Employee #36 obtained gauze for the dressing change, droplets of blood dripped from the resident's wound onto the mattress, creating a small pool of blood. Neither the nurse nor the nursing assistant sanitized the bed, which had been contaminated with the bloody gauze and pool of blood. During an interview with LPN #36, immediately after exiting the room, the nurse confirmed the following: -- the bed had not been sanitized, -- staff utilized improper technique for hand sanitation, and -- staff utilized improper technique for wound cleansing. The nurse confirmed the practices created a potential for cross contamination. The nurse also related the resident was not supposed to utilize a sheet because it interfered with circulation and the wound healing process. Upon inquiry, the nurse confirmed the incontinence pads created a potential to prevent wound healing. c) The hospital wound dressing policy, reviewed on 03/02/14 at 5:00 p.m., indicated staff should cleanse the wound using a circular motion beginning at the center of the wound and extending outward. The policy directed staff to utilize universal (standard) precautions when discarding disposable items. d) Review of the facility's handwashing policy and the hand hygiene alcohol-based hand rub policy, on 03/02/15 at 4:50 p.m., found the policies required staff cleanse hands and fingers for a minimum of 15-20 seconds. Additionally, the policy indicated staff would sanitize hands before and after applying gloves, after contact with a resident's intact skin, and after contact with inanimate objects in the immediate vicinity of the resident. e) The director of nursing (DON), interviewed on 03/03/15 at 10:00 a.m., confirmed staff failed to utilize proper techniques when washing/sanitizing hands and cleansing a wound. The DON acknowledged the practice created a potential for cross contamination, creating a potential for the transmission and spread of disease and infection. | 2018-09-01 |