cms_GA: 10643

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

Data source: Big Local News · About: big-local-datasette

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rowid	facility_name	facility_id	address	city	state	zip	inspection_date	deficiency_tag	scope_severity	complaint	standard	eventid	inspection_text	filedate
10643	WILLOWWOOD NURSING CENTER	115327	4595 CANTRELL ROAD	FLOWERY BRANCH	GA	30542	2011-03-10	490	K			82I011	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, record review and staff interviews, the facility failed to be administered in a manner that ensured staff members were trained appropriately regarding the need to clean and disinfect glucometers between each resident. This affected 21 residents currently in the facility who received daily monitoring of blood glucose levels where mult-use glucometers are used. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety for those 21 residents. Therefore, it was determined that the likelihood of an immediate and serious threat to resident health and safety existed from March 8, 2011 until March 10, 2011 when a plan of correction was implemented by the facility to remove the jeopardy situation. Findings include: Interview on 3/8/11 at 1:00 p.m. with the Administrator, Director of Nursing (DON) and the Clinical Education Director revealed that the DON was unaware of the revision to F441 dated July 17, 2009 and was that the DON and the Clinical Education Director were not familiar with the facility Policy for cleaning and disinfecting of the blood glucose monitors. Review of the facility policy Cleaning/Disinfecting Glucometers with creation date of 4/30/10 and fax date of 3/08/11, from the corporate office, revealed that alcohol should never be used, as it can damage the LED (light emitting diode) readout and the machine, if no visible soil is present, should be disinfected after each use following the manufacture direction or wipe with a cloth damped with EPA (environmental protection agency) registered detergent/germicide that has a TB ([MEDICAL CONDITION]), HBV ([MEDICAL CONDITION]),[MEDICAL CONDITION](human immunodeficiency virus) label or dilute beach solution of 1:10 concentration, and allow to self dry. At this time the DON revealed that he had an in-serviced and instructed all professional staff to clean the blood glucose monitors with an alcohol wipe before and after use. The facility failed to have a system in place to ensure infection control guidelines were implemented for cleaning and sanitizing blood glucose monitors between residents. The immediate and serious threat to resident health and safety was determined to have been removed on March 10, 2011 but, the associated noncompliance continues in order to ensure the following are maintained by the facility: blood glucose monitors are cleaned and disinfected according to the facility revised policy and procedure: all residents identified with the potential for blood borne pathogens have an individual blood glucose monitoring machine; all licensed staff are in-serviced on procedures related to cleaning and disinfecting blood glucose monitors; and the ongoing implementation of and monitoring of compliance with the facility's revised infection control policy related to cleaning and disinfecting blood glucose monitors. Therefore, the scope and severity of the deficiency was reduced from a "K" level to an "E" level when the facility implemented the following plan of correction: 1. The revised policy and procedure (of 4/2010) entitled "Cleaning and Disinfecting Glucometers" was reviewed and approved by the facility Administrator, DON and the Medical Director. The revised policy became effective 3/08/11 and was revised in conjunction with CDC guidelines, EPA literature, and manufacturer's recommendations. The policy and procedure read: Purpose: To prevent the spread of communicable disease and infection as related to multi use blood glucose monitoring equipment. 1.-Place monitor on a clean, dry surface 2.-Wash hands and apply gloves 3.-Use Santi Cloth Plus Germicidal Disposable Cloth (EPA reg. no: 9480-6) for twenty seconds to clean the front and back of the glucose monitor. Discard cloth after use. 4.-Place monitor in a clean plastic cup to air dry for five (5) minutes, discard cup after use. 5.-After use, clean glucometer again with Sani Cloth Plus Germicidal Disposable Cloth. 6.-Remove gloves and wash hands. Glucometer must be disinfected before and after each use. 2. A new facility policy was developed for residents identified with potential Blood Borne Pathogens such [MEDICAL CONDITIONS] to have an individual glucose machine. This machine will be resident specific and will be labeled, bagged and kept in a separate area of the medication cart. Completion 3/09/10 3. In-services of all licensed nursing staff were conducted regarding the revised policy and procedures related to blood glucose monitor cleaning and disinfecting. The in-services included a return demonstration by all nurses in attendance. Training sessions were conducted by the DON on 3/08/11 at 4:10 p.m., 4:15 p.m., 5:30 p.m., 7:15 p.m., 7:30 p.m., 8:00 p.m., 10:30 p.m. and 11:30 p.m. and on 3/09/11 at 7:40 a.m. There are no licensed staff currently on leave of absence or unavailable to attend the in-services.. All new hires of licensed staff will be in-serviced as part of the orientation process. Completed 3/09/11 4. A copy of the revised policy and procedure was placed on each medication cart. Completed on 3/08/11. 5. Monitoring for compliance to be conducted to be conducted daily by the DON or Clinical Education Manager for two (2) weeks, then weekly for two (2) weeks, and each quarter there after to include all shifts. Monitoring will include observation of return demonstration by twenty five (25) percent of random licensed staff per shift for residents receiving blood glucose monitoring per day. 6. Prevention measures regarding Infection Control and compliance with revised policy will be included in the facility's weekly Patient's at Risk (PAR) committee and preventive measures will also be reviewed each quarter by the Quarterly Assurance Committee. Initial meeting 3/09/11. Observation of the cleaning and disinfecting of the blood glucose monitors between resident use was conducted on 3/09/11 with Licensed Practical Nurses (LPN) "AA", "BB", "CC", "HH", "II" and Registered Nurse (RN) "EE" from 11:22 a.m. until 3:52 p.m. and verification of in-service and return demonstration for LPNs "FF", "GG" and RN "QQ" on 3/10/11 at 6:11-9:45 a.m. These observations revealed compliance with the revised facility policy and procedure. Additional Interviews were conducted with those licensed staff on the night and weekend shifts on 3/09/11 and 3/10/11 to verify attendance at an in-service regarding cleaning and disinfecting of the blood glucose monitors and knowledge of the new policy and procedure. Completion on 3/10/11.	2014-01-01