| 91 |
SENIOR REHAB & RECOVERY AT LIMESTONE HEALTH FACILI |
15024 |
1600 WEST HOBBS STREET |
ATHENS |
AL |
35611 |
2020-02-13 |
880 |
D |
0 |
1 |
SQ2Q11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, medical record review, and review of a facility policy titled Hand Hygiene, the facility failed to ensure: 1) a Licensed Practical Nurse (LPN) washed hands or used hand sanitizer after administering Resident Identifier (RI) #213's nebulizer treatment and placing a garbage bag in the medication cart garbage can, prior to reentering RI #213's room to clean RI #213's facemask; and 2) a Certified Nursing Assistant (CNA) washed hands or used hand sanitizer after she emptied RI #105's urinal, prior to exiting RI #105's room. This affected one of four residents observed during medication administration pass and one of one sampled resident for whom a CNA was observed emptying a urinal. Findings Include: A review of a facility policy titled Hand Hygiene, with a date of 7/30/2016, revealed . Hand Hygiene procedures include the use of alcohol-based hand rubs . and handwashing with soap and water . Always perform hand hygiene in the following situations . Before exiting the patient's care area after touching the patient or the patient's immediate environment . after glove removal . 1) RI #213 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/13/20 at 9:04 a.m., the surveyor observed Employee Identifier (EI) #7, a LPN, during medication administration pass for RI #213. EI #7 gave RI #213's nebulizer treatment and placed a plastic garbage bag in the medication cart garbage can. EI #7 did not wash or sanitize her hands prior to reentering RI #213's room. EI #7 then cleaned RI #213's facemask attached to the nebulizer machine, removed her gloves, and did not wash or sanitize her hands prior to exiting RI #213's room. On 2/13/20 at 9:56 a.m., the surveyor conducted an interview with EI #7, a LPN. EI #7 was asked what she should have done after she started RI #213's nebulizer treatment, placed a plastic garbage bag in the medication cart garbage can, and prior to reentering RI #213's room. EI #7 stated she should have washed her hands or used hand sanitizer. EI #7 was asked what she should have done after she removed her gloves after cleaning RI #213's facemask, prior to leaving RI #213's room. EI #7 stated she should have washed her hands or used hand sanitizer. EI #7 was asked what the facility hand washing/hygiene policy stated should be done after a licensed nurse touched a resident's equipment, environment, and prior to leaving a resident's room. EI #7 stated staff should wash hands or use hand sanitizer. EI #7 was asked what would be the concern in not washing hands or using hand sanitizer after a licensed nurse started RI #213's inhalation nebulizer treatment, placed a plastic garbage bag in the medication cart garbage can, and prior to reentering RI #213's room. EI #7 stated it could spread germs to everyone and they could get an infection. EI #7 was asked what would be the concern if a licensed nurse did not wash her hands or use hand sanitizer after she cleaned RI #213's facemask, removed her gloves, and prior to leaving RI #213's room. EI #7 stated it could spread germs to everyone and they could get an infection. EI #7 said she forgot to wash her hands. On 2/13/20 at 11:06 a.m., the surveyor conducted an interview with EI #6, Infection Control Preventionist/Registered Nurse (RN). EI #6 was asked how are the licensed staff trained at the facility on hand hygiene. EI #6 was asked what a licensed nurse should do after after she started RI #213's inhalation nebulizer treatment, placed a plastic garbage bag in the medication cart garbage can, and prior to reentering RI #213's room. EI #6 stated she should have washed her hands or use hand sanitizer. EI #6 was asked what should a licensed nurse have done after she cleaned RI #213's facemask, removed her gloves, and prior to leaving RI #213's room. EI #6 stated she should have washed her hands or used hand sanitizer prior to leaving the room. EI #6 was asked what the facility policy on hand hygiene stated should be done after a licensed nurse touched a resident's equipment, environment and prior to leaving a resident's room. EI #6 stated staff should wash hands or use a hand sanitizer. EI #6 was asked what would be the concern if a licensed nurse did not wash her hands after she started RI #213's inhalation nebulizer treatment, placed a plastic garbage bag in the medication cart garbage can, and prior to reentering RI #213 room. EI #6 stated it could have spread an infection. EI #6 was asked what would be the concern if a licensed nurse cleaned RI #213's facemask, removed her gloves and did not wash her hands prior to leaving the room. EI #6 stated there was a potential to spread an infection. 2) RI #105 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 2/11/20 at 11:49 a.m., EI #9, a CNA, was observed removing soiled gloves after she emptied RI #105's urinal. EI #9 placed her gloves into the trash can and exited the room without washing her hands. An interview was conducted on 2/11/20 at 11:54 a.m EI #9 was asked what she was doing in RI #105's room. EI #9 said, emptying the urinal, and then placed the urinal back on the side of the bed. EI #9 further stated she threw her gloves in the trash can and did not wash her hands before exiting RI #105's room. The surveyor asked EI #9 if she was supposed to wash her hands after emptying the urinal, before exiting the room. EI #9 replied yes, to prevent the spread of germs, cross contamination and break in infection control. On 02/13/20 at 10:19 a.m., an interview was conducted with EI #6, Infection Control Preventionist/RN. EI #6 said staff should wash their hands before and after resident care, including after emptying a urinal. The surveyor asked EI #6 why staff should wash their hands after emptying a urinal. EI #6 replied, to decrease the spread of infection. |
2020-09-01 |