cms_GA: 4053
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4053 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2018-08-19 | 584 | E | 0 | 1 | EQDC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the policy titled Enteral Nutrition Pump- Cleaning and Disinfection and staff interviews, the facility failed to maintain tube feeding poles in a clean and sanitary condition for nine of 17 resident (R) (#25, #3, #7, #76, #10, #9, #14, #15, and #178) that received enteral tube feeding, and failed to maintain clean and dust free hallway walls in one of two units (Unit 1). Findings include: 1. Observations of the tube feeding pole for R#25 on 8/17/18 at 12:00 p.m., on 8/18/18 at 8:40 a.m. and 11:30 a.m., and on 8/19/18 at 8:50 a.m. revealed dried, heavily splattered tube feeding on the base and wheels of the pole. 2. Observations of the tube feeding pole for R#3 on 8/17/18 at 12:45 p.m., on 8/18/18 at 8:30 a.m., 11:35 a.m. and 2:40 p.m., and on 8/19/18 at 8:40 a.m. revealed dried, heavily splattered tube feeding on the base and wheels of the pole. 3. Observations of the tube feeding pole for R#7 on 8/17/18 at 1:00 p.m., on 8/18/18 at 8:25 a.m., 11:40 a.m. and 2:36 p.m., and on 8/19/18 at 8:45 a.m. revealed dried, heavily splattered tube feeding on the base and wheels of the pole. 4. Observation of the tube feeding pole for R#76 on 8/17/18 at 1:15 p.m., on 8/18/18 at 9:05 a.m., 11:45 a.m. and 2:43 p.m., and on 8/19/18 at 8:30 a.m. revealed dried, heavily splattered tube feeding on the base and wheels of the pole. 5. Observations of the tube feeding pole for R#10 on 8/17/18 at 1:10 p.m., on 8/18/18 at 9:10 a.m., 11:50 a.m. and 2:40 a.m., and on 8/19/18 at 8:35 a.m. revealed dried, heavily splattered tube feeding on the base and wheels of the pole. 6. Observation of room [ROOM NUMBER] on 8/17/18 beginning at 2:58 p.m. revealed the tube feeding pole for Resident (R)#9 in bed A had a large amount of dried, beige-colored substance on the base of the pole. Observation of room [ROOM NUMBER] on 8/18/18 beginning at 10:50 a.m. revealed the tube feeding pole for R#9 in bed A had a large amount of dried, beige-colored substance in the base of the pole. Observation of room [ROOM NUMBER] on 8/19/18 beginning at 9:56 a.m. revealed the tube feeding pole for R#9 in bed A had a moderate amount of dried, beige-colored substance on the base of the pole. There was a housekeeping log sheet titled, Camelia Unit Pole Accountability, on the back of the door of room [ROOM NUMBER] which documented the tube feeding pole for bed A was cleaned on 8/18/18 and 8/19/18, however, a moderate amount of dried, beige-colored substance remained on the base of the pole. 7. Observation of room [ROOM NUMBER] on 8/17/18 beginning at 2:58 p.m. revealed the tube feeding pole for R#14 in bed B had a large amount of dried, beige-colored substance on the base of the pole. Observation of room [ROOM NUMBER] on 8/18/18 beginning at 10:50 a.m. revealed the tube feeding pole for R#14 in bed B had a large amount of dried, beige-colored substance on the base of the pole. Observation of room [ROOM NUMBER] on 8/19/18 beginning at 9:56 a.m. revealed the tube feeding pole for R#14 in bed B had a moderate amount of dried, beige-colored substance on the base of the pole. There was no housekeeping log sheet available for R#14 in bed B. 8. Observation of room [ROOM NUMBER] on 8/17/18 beginning at 2:58 p.m. revealed the tube feeding pole for R#15 in bed C had a large amount of dried, beige-colored substance on the base of the pole. Observation of room [ROOM NUMBER] on 8/18/19 beginning at 10:50 a.m. revealed the tube feeding pole for R#15 in bed C had a large amount of dried, beige-colored substance on the base of the pole. Observation of room [ROOM NUMBER] on 8/19/18 beginning at 9:56 a.m. revealed the tube feeding pole for R#15 in bed C had a moderate amount of dried, beige-colored substance on the base of the pole. There was no housekeeping log sheet available for R#15 in bed C. 9. Observations of the tube feeding pole for R#178 on 8/17/2018 at 11:00 a.m. revealed dried, heavily splattered tube feeding on the pole, base and wheels. Observations of the tube feeding pole for R#178 on 8/18/2018 at 9:44 a.m. revealed dried, heavily splattered tube feeding on the pole, base and wheels. Observations of the tube feeding pole for R#178 on 8/19/2018 at 9:30 a.m. revealed dried, heavily splattered tube feeding on the pole, base and wheels. There was no housekeeping log sheet available for R#178. Observation on 8/17/18 at 1:33 p.m. there was brown dripping stains on walls and dust on lower portion of walls in hallway throughout living unit one. Observation on 8/18/18 at 8:47 a.m. there was brown splatter stains on right side of the wall near the window. Observation on 8/18/18 at 8:49 a.m. There were brown stains on wall near rooms [ROOM NUMBERS] that looks like spillage. There was also black staining noted towards the lower areas of the wall. There continues to be dust on walls throughout the hallway of unit one. Interview on 8/19/18 at 11:34 a.m. with the on-call Housekeeping Team Leader who reported that housekeeping staff should pull trash, make beds, clean restroom, clean activity rooms, and closets. It was further reported resident rooms should be wiped down to include the walls. Housekeeping tour began at 8/19/18 11:38 a.m. with on-call Housekeeping Team Leader and the following was confirmed: 1. Observation in room [ROOM NUMBER] revealed splatter on wall. 2. Observation of hallway across from room [ROOM NUMBER] and room [ROOM NUMBER] revealed dust buildup on lower wall and dripping stains on walls. 3. Loose baseboards near room [ROOM NUMBER] and near water fountain unit 1. 4. There was dust buildup under sink in hallway and dust buildup on walls throughout Unit 1. During an interview with the on-call Housekeeping Team Leader on 8/19/18 at 11:50 a.m. it was reported that inspections are supposed to be done weekly by the supervisor to assure that areas are being cleaned. She further reported that when she does her inspections if areas of concerns are identified the worker is notified to correct the issue. She further reported that as areas are identified the expectation is that the areas will be cleaned. Interview on 8/19/18 at 12:15 p.m. with Nurse Manager who reported that it is the expectation that staff will correct an issue if they see it, when addressing the splatter stains on the wall in room [ROOM NUMBER]. Explaining that they can wipe something and clean it instantly, but if they are not able to clean they are to notify housekeeping so that they can address the issue. She further reported that the stains in the hallway look as if someone sprayed something and did not wipe the wall thereafter. Observation on 8/19/18 with the Nurse Manager beginning at 10:00 a.m. and ending at 10:20 a.m. confirmed the tube feeding poles and bases were dirty and had dried tube feeding drippings on the base for R#25, R#3, R#7, R#76, R#10, R#9, R#14, R#15 and R#178. She confirmed that the tube feeding nozzles for R#76 and R#10 was not in use but was not capped off. The Nurse Manager stated she had spoken with the staff about ensuring the tube feeding nozzles were capped off when not in use and to keep the caps in the plastic bag at bedside when tube feeding was in use. She confirmed that not capping off the tube feeding nozzles could cause dripping unto the base of the pole and the floor. She stated that it is just a matter of laziness. She stated she just spoke with staff about this last Wednesday. The Nurse Manager stated the responsibility to ensure the poles are clean is between both the nurses and the housekeeping staff. She stated that housekeeping had tried to clean the poles bases before and that the tube feeding had dried to the point they had trouble removing it. The Nurse Manager confirmed that if the caps were properly used and the tube feeding was wiped off when it drips or on a regular basis, it would not be dried to the point of difficult removal and cleaning. The Nurse Manager stated they had discussed getting new tube feeding poles but had not yet ordered any. Interview on 8/19/18 at 12:25 p.m. with the Nurse Manager revealed they do not have a policy for cleaning the tube feeding poles and that the current policy only addresses cleaning the kangaroo pump itself. She further stated they do not have a policy and procedure related to capping the tube feeding nozzles when disconnected from the residents and not in use. Review of the policy titled Eternal Nutrition Pump- Cleaning and Disinfection approved 4/14/10 documented A pump in continuous client use will be surface cleaned of all spills on the living area as needed or at least weekly. The policy did not address cleaning of the pump pole. | 2020-09-01 |