cms_WV: 7509
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 7509 | MOUND VIEW HEALTH CARE | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2013-06-13 | 441 | F | 0 | 1 | 9DS111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, manufacturers' product descriptions, staff interview, and policy review, the facility failed to develop and implement effective infection control practices. The facility failed to follow manufacturers' product information for single use resident items (wash basins and bedpans), did not ensure linen was handled in a safe and sanitary manner, staff failed to sanitize their hands during dispensing of ice and snacks to residents, failed to ensure Resident #96's toothbrush was stored in a sanitary manner, failed to ensure two (2) residents (#94 and #31) received proper catheter and/or peri care, failed to ensure bedpans were maintained to ensure use by the same person and were stored properly, and failed to ensure two (2) residents (#154 and #23) were cohorted appropriately. Thes issues had the potential to affect more than a limited number of residents. Resident identifiers: #94, #31, #96, #154, #23, #50, and #109. Census: 113. Findings include: a) Resident #94 A nurse aide (NA), Employee #164, was observed performing pericare and catheter care on Resident #94 on 06/11/13 at 9:00 a.m. The employee donned her gloves and then proceeded to pick up the fall mat off of the floor next to the resident's bed. Without changing her gloves, she sprayed baby wipes with an antimicrobial personal cleaner called [MEDICATION NAME] and began wiping the perineal area from front to back without changing wipes or folding them. She then cleaned the catheter tubing twice with the same wipe, wiping from proximal to distal. After the resident was redressed and covered, the NA picked up an alcohol wipe from the bedside table and cleansed the end of the drainage tubing before emptying the catheter bag. After emptying the catheter bag, she picked up a second alcohol wipe from the bedside table and cleaned the tubing before securing it to the catheter bag. She did not change her gloves. A review of the procedure was conducted with Employee #164 immediately after the procedure. She agreed the bedside table should have been covered to prevent her from contaminating it when she picked up the alcohol wipes with her contaminated gloves on. She also agreed she should not have completed pericare and catheter care with the same pair of gloves that she had picked up the floor mat with. In addition she acknowledged the [MEDICATION NAME] spray bottle she had just used had a brown colored substance in the groves of the cap and needed to be replaced. b) Resident #31 A second observation was conducted on 06/11/13 at 1:40 p.m., nursing aide (NA) Employee #88 was observed performing pericare and catheter care on Resident #31. She donned her gloves and then proceeded to gather her equipment and pull the window and bedside curtains closed. She then placed her baby wipes and [MEDICATION NAME] personal care cleaner on the bedside table. She discarded the first baby wipe after wiping once from front to back. The second and third baby wipes were used four (4) and five (5) times each, going deep into the resident's skin folds. Another wipe was then used repeatedly to wipe the catheter from proximal to distal end. The NA then cleaned up the area and opened the curtains before removing her gloves and washing her hands. During a review of the procedure immediately after she agreed she had left her dirty gloves on and had now contaminated the curtains and bedside table. She also agreed she should have only used the cloths once because of possible contamination from the rectal are and should have covered the bed side table before starting. c) An interview was conducted with the nurse educator, Employee #103, on 06/11/13 at 2:00 p.m. She stated the policies were routinely revised by the assistant director of nursing and it should not say to fold a wash cloth over and reuse. The staff should be using baby wipes and only using each wipe only once and then it should be discardd. Employee #103 taught personal care skills annually, but did not routinely perform observations of staffs' personal care and hygiene techniques. d) Observation on 06/06/13 at 11:30 a.m. found a plastic bed pan stored directly on the bathroom floor in room [ROOM NUMBER]. There was no name to indicate ownership, and it was not contained in any type of storage bag. The previous day, a bed pan was observed sitting behind the grab bar on the wall by the toilet in this bathroom, approximately ten (10) inches above the roll of toilet paper. A nurse, Employee #60, said residents' bedpans were to be cleaned, then stored in the bedside stand. She was shown the bedpan that was sitting directly on the bathroom floor and said she would take care of it. Also at this time, a bedpan was observed sitting directly on the bathroom floor in room [ROOM NUMBER]. Again, there was no name to indicate ownership, and there was nothing covering the bedpan. Activity aide/nursing assistant, Employee #82, was shown this bedpan and said she see that it was taken care of. An interview was conducted with the wing charge nurse, Employee #45, on 06/06/13 at 11:55 a.m. She said bedpans were supposed to be stored in plastic bags in the bottom drawer of the bedside stands. e) A random observation on 06/06/13 at 11:50 a.m. found a nursing assistant, Employee #117, exiting a resident room on the 200 wing, with soiled, unbagged bed linens held directly against her uniform. There was at least a bed pad and a sheet. The latter was visibly soiled with bowel movement. Activity aide/nursing assistant, Employee #82, observed this scenario, and said that people do things differently. Employee #117 carried the linens in this manner down the hallway to the soiled utility area. This was reported to a nurse, Employee #45, on 06/06/13 at 11:55 a.m. She said staff were supposed to wear gloves, and transport soiled linens in a bag to the soiled utility room, without touching their clothing with soiled linens. f) Resident #96 An interview was conducted with nursing assistants, Employees #69, #84, and #87 on 06/12/13 at 2:15 p.m. They said that staff assisted this resident to walk to the bathroom to brush his teeth. When asked to find his toothbrush, the aides looked in his bedside table and found none. They then located a cream colored toothbrush that was lying directly on the sink in the bathroom. The handle portion was in the plastic wrap, and the head of the toothbrush was out of the plastic wrap, lying directly on the sink behind the faucet handles. An interview was conducted with a nurse, Employee #136, on 06/12/13 at 2:30 p.m. She saw the cream colored toothbrush with the head lying directly the bathroom sink. She said the toothbrush was not supposed to be stored in that manner, and got him a new toothbrush. g) Resident #154 and #23 Medical record review revealed Resident #23 was admitted to the facility on [DATE]. She had a urine culture that indicated [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE) on 05/18/13. She was in contact precautions from 05/18/13 until 05/20/13, when contact isolation was discontinued. Review of the Minimum Data Set (MDS), with an assessment reference date (ARD) of 04/05/13, found she was always incontinent of urine and stool. On 05/22/13, Resident #154 was admitted to the same room. Resident #154 had a Foley catheter on admission, and has had a Foley ever since then. She also had sustained a recent hip fracture and repair. She had staples in place initially, and for several days after admission to the facility. Medical record review found no evidence that Resident #154 had any history of VRE. During an interview with the Assistant Director of Nursing, on 06/10/13 at 2:30 p.m., she said they try to place residents with any type of multi-drug resistant organisms (MDRO) in a private room. If no private room was available, they cohorted residents. She said, for example, that you would not put a resident who had a portal, such as a Foley catheter, intravenous line, or gastrostomy tube, in the same room as a resident with a MDRO. She provided information from the facility's Infection Control Manual, Policy #78 B. This policy indicated a resident with a MDRO was to be placed in a private room. When a private room was not available, to place the patient in a room with a patient who had an active infection with the same microorganism, but with no other infection (cohorting). When a private room was not available and cohorting was not achievable, to consider the epidemiology of the microorganism and the patient population when determining patient placement. Consultation with infection control professionals was advised before patient placement. When asked about roommates, Residents #23 and #154, she said that both residents had the same physician, #172, and he said it was all right to have them in the same room. She said the physician said Resident #23 did not have a VRE infection. An interview was conducted with Physician #172 on 06/10/13 at 3:00 p.m He said that Resident #23, because of her fistula, would always be growing something in her urine. He said they did culture and sensitivity reports periodically on her urine. He said that Resident #23 was not spreading infection, and that Resident #154 would have her catheter for only a short while longer. When asked if the facility had policies about who they may or may not cohort with a resident who has VRE, whether active or colonized, to preclude rooming with those who have portals such as a Foley catheter, he said he would have to speak with the director about that as he was not certain. An interview was conducted with nursing assistants, Employees #157 and #117, on 6/11/13 at 10:10 a.m. They said that Resident #23 sometimes was continent, and sometimes was incontinent and used her brief. h) Resident wash basins and some bed pans were not being used as single patient use items per manufactures' product information that described the items as Single patient use. These items were not labeled with resident names and were observed being disinfected for re-use by other residents. On 06/03/13 at 11:15 a.m., observations of the soiled utility room between the 100 wing and the 300 wing noted an unlabeled metal and [MEDICATION NAME] (plastic) bedpan sitting in the right side of a double sink with soapy water in it. On the left side of the double sink were unlabeled wash basins. At 11:20 a.m. Employee #40, a Licensed Practical Nurse (LPN), viewed the unlabeled bedpans and wash basins in the soiled utility sinks. She said these items were in the sink to be disinfected by night shift with 531 solution. At 11:45 a.m. Employee #38, a Registered Nursing Assistant (RNA), was observed disinfecting the unlabeled bedpans and wash basins that were placed in the same sink (the left side of the double sink) with 531 solution. The RNA said after the items were disinfected, they were dried and placed in the clean utility room for staff to use for any residents. She also commented this was the facility procedure for cleaning of resident items/equipment. During a confidential interview with a RNA, on 06/03/13, the RNA commented it was not sanitary to clean bed pans and wash basins and then given them to other residents, but this was what the facility had them do with these items. i) Residents #50 and #109 On 06/04/13 at 10:30 a.m., a random observation revealed Employee #156, a hospitality aide (HA) removed a container of Cheerios with milk, and a spoon from room [ROOM NUMBER]. She said it belonged to Resident #50. The HA opened the box on the cart and obtained snacks. She did not cleanse her hands after touching the soiled items, and prior to obtaining items from the snack container. She provided the snacks to Resident #50. Employee #156 removed her gloves, donned a new pair, and entered room [ROOM NUMBER]. She provided a snack to Resident #109, then went to the ice/snack cart, and poured ice and water. She removed her gloves and donned new ones. She did not sanitize her hands. The HA then poured ice for the roommate. . | 2017-04-01 |