| 20 |
HIGHLANDS HEALTH AND REHAB |
15012 |
380 WOODS COVE ROAD |
SCOTTSBORO |
AL |
35768 |
2017-03-16 |
441 |
E |
0 |
1 |
WKAI11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and a review of facility policy's titled: Laundry, Hand Hygiene, and Cleaning of Glucose Meter, the facility failed to ensure the following: 1) Clothing items were free of a brown substance after being washed with other resident clothing items. This affected 19 residents receiving laundry services through the facility. 2) Employee Identifier (EI) #3 Certified Nursing Assistant (CNA) removed her soiled gloves and washed her hands while providing incontinent care for Resident Identifier (RI) #4. 3) EI #7 Licensed Practical Nurse (LPN) cleaned the glucometer after checking RI #9's blood sugar. This affected one of one observation of a finger stick during the medication pass on 03/15/17. Findings Include: 1) A review of a facility policy titled, Laundry with a revised date of 05/2011 revealed the following: .Policy: Laundry will be handled in a safe manner .Procedure: .7. The department responsible for ensuring the proper handling . or cleaning of all laundry is Environmental Services. On 03/15/2017 at 9:05 a.m., an observation was made of wet/damp clothing items in a barrel with a pair of black sweat pants with a brown substance. EI #4, Environmental Service Supervisor was asked to observe the clothing item. EI #4 was asked what did the substance look like. EI #4 replied, feces. EI #4 was asked were the clothing inside of the barrel with the black sweat pants already washed. EI #4 replied yes ma'am. EI #4 was asked how were items with visible soiled areas such as feces to be handled in the laundry. EI #4 explained if laundry staff washed items with visible feces they would separate them from other resident clothing items. EI #4 was asked why should visibly soiled clothing items with feces be washed separately from other resident clothing items. EI #4 replied because it would contaminate the rest of the laundry. EI #4 was asked what was the potential harm in washing clothing items with visible substance such as feces with other resident clothing items. EI #4 replied it could cause cross contamination. On 03/16/2017 at 9:20 a.m., an interview was conducted with EI #6, Infection Control Coordinator. EI #6 was asked should a substance identified as bowel movement be observed on an item that has been washed with other clothing items. EI #6 stated,No. 2) A facility policy titled: Hand Hygiene . with an Effective Date: 5/15/2008 .7. Hand hygiene: A general term that applies to any of the following: hand washing, antiseptic hand wash, antiseptic hand rub . B. Indications for hand washing and hand antisepsis . 3. Perform hand hygiene: a. before and after having direct contact with patients . b. after removing gloves . d. after contact with body fluids or excretions, mucous membranes, intact skin, or wound dressings RI #4 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #4's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/16/17, documented RI #4 as incontinent for bowel and bladder. During an observation of incontinent care for RI #4 on 03/15/17, at 4:25 p.m. EI #3 CNA was observed repeatedly touching RI #4's bottle of peri-wash with the same gloves used to provide the incontinent care. EI #3 failed to remove the soiled gloves and wash her hands before touching RI #4's privacy curtain, and placed his/her clean brief on the bed and touched the container of barrier cream. An interview was conducted with EI #3 CNA on 03/16/17, at 11:29 a.m. She was asked what care she provided for RI #4 on 03/15/17 with the surveyors present. EI #3 replied, perineal care. She was asked if RI #4 was incontinent and of what. EI #3 replied, yes ma'am of urine. EI #3 was asked why she repeatedly picked up a bottle of peri-wash with soiled gloves. She stated, No excuse I just was not paying attention. EI #3 was asked what she should have done. She stated, I should have put the peri-wash on the cloths before I started. EI #3 was asked why she failed to remove her soiled gloves and wash her hands before she touched RI #4's clean brief, privacy curtain and barrier cream container. She stated, I knew I messed up after I got done and thought about it. EI #3 was asked what the potential for harm was if soiled gloves were used and hands were not washed before touching a residents clean brief, privacy curtain and barrier cream container. She replied, contamination of the perineal area and anything else I touch. EI #3 was asked if RI #4 had a Urinary Tract Infection. She stated, I think she has had on that I know of. An interview was conducted with EI #5 CNA on 03/16/17, at 11:50 a.m. She was asked what care she had assisted with for RI #4 on 03/15/17 with EI #3. EI #5 replied, perineal care. EI #5 was asked what the potential for harm was if soiled gloves were used to touch clean items during incontinent care. EI #5 stated, Contamination. An interview was conducted with EI #6 Infection Control Coordinator on 03/16/17 at 9:20 a.m. EI #6 was asked what should a CNA do with soiled gloves before touching a bottle of perineal wash repeatedly, a residents privacy curtain and clean brief. EI #6 stated, Gloves should be removed, hand hygiene performed and new gloves put on. EI #6 was asked what infections he was currently monitoring in the facility. He replied, to include UTI (Urinary Tract Infection). 3) A facility policy titled: Cleaning of Glucose Meter . with an effective date of 7/15/14 . POLICY This policy and procedure is to address the cleaning of Glucose Meter . CLEANING PR[NAME]EDURE 1. The meter must be cleaned between patients and prior to docking using approved disinfectant wipe. Resident Identifier (RI) #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #9's (MONTH) (YEAR) Physician order [REDACTED]. An observation of a fingerstick blood sugar check was observed on 03/15/17, at 4:00 p.m. by EI #7 LPN. EI #7 obtained the blood sugar from RI #9 and failed to clean the glucometer before placing it in the top draw of the medication cart. An interview was conducted with EI #7 on 03/15/17, at 6:00 p.m. EI #7 was asked what was the facility's policy related to cleaning the glucometer. EI #7 stated, Clean between each resident. EI #7 was asked why she failed to clean the glucometer after she used it for RI #9. She stated, Nerves. I don't usually work on the cart we had an emergency. EI #7 was asked if she should have cleaned it after obtaining RI #9's blood sugar. She stated, Yes. EI #7 was asked what the potential for harm was if the glucometer was not cleaned after each resident. She stated, Spread of Infection. An interview was conducted with EI #6, Infection Control Coordinator on 03/06/17 at 9:20 a.m. EI #6 was asked what the potential for harm was if the glucometer was not cleaned after using it with a resident. EI # 6 stated, High potential for Hepatitis C, B and blood borne pathogens. EI #6 was asked what should a nurse to do with the glucometer after using it with a resident. EI #6 stated, Wiped down with a peroxide wipe. |
2020-09-01 |