| 511 |
DOUGLASVILLE NURSING AND REHABILITATION CENTER |
115273 |
4028 HWY 5 |
DOUGLASVILLE |
GA |
30135 |
2019-01-11 |
880 |
F |
0 |
1 |
ZVL511 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and policy reviews the facility failed to provide evidence that infection control surveillance data was collected in (MONTH) of (YEAR). Failed to provide documentation that infection control data collected in (MONTH) of (YEAR) was analyzed for trends and appropriate actions taken in response. In addition, the facility failed to do the following; conduct annual review and update their policies and infection prevention control program (IPCP); failed to don appropriate personal protective equipment (PPE) when entering a resident's room on transmission-based precautions; failed to use hand hygiene prior to donning PPE and during medication administration. The facility census was 220. Findings included: Review of an undated policy titled, Surveillance For Healthcare Associated Infections revealed; Policy Surveillance for Healthcare Associated Infections will be completed to calculate baseline rates, detect outbreaks, track progress, and to determine trends to help prevent the development or spread of infection (HAI). Procedure 3. Complete the Monthly Control Surveillance Log utilizing a new form each month. 1. Review of the Monthly Healthcare-Associated Infection (HAI) Report dated (MONTH) (YEAR)-November (YEAR) revealed facility did not have collected surveillance data for the month of (MONTH) (YEAR). Review of the Monthly Healthcare-Associated Infection (HAI) Report dated (MONTH) (YEAR) 18 revealed total infection cases; 1 UTI's with a Foley, 8 UTI's without a Foley, 3 URI, 2 LRI, 2 pressure ulcers, 2 skin, 1 [MEDICAL CONDITION], 1 other. Further review of the (MONTH) infection control data revealed that no infection control surveillance log was done nor summary of the infections. An interview was conducted on 12/19/18 at 11:45 a.m. with the Director of Nursing (DON) confirmed that the Monthly Infection Control Surveillance log should be used/completed per the policy. 2. Review of the IPCP no evidence that the facility was conducting an annual review of their program. An Interview was conducted on 12/17/18 at 5:15 p.m. with Infection Control Preventionist (ICP). The ICP revealed the infection control policies and manual is updated annually and as needed. The following Policy were provided to the surveyor by the DON and reviewed by the surveyor: 1. Surveillance For Healthcare Associated Infections undated policy 2. Communicable Disease Reporting dated 10/09 3. Management Of Communicable Diseases dated 10/09 4. [MEDICAL CONDITION] Surveillance dated 10/09 5. Standard Precautions dated 10/09 6. Contact Precautions dated 10/09 7. Droplet Precautions dated 10/09 8. Regulated Infectious Waste dated 10/09 9. Stool Specimen dated 10/09 10. Laundry Handling dated 10/09 11. Multi Drug Resistant Organisms (MDROs) dated 10/09 12. Hand Washing dated 8/17 13. Ear Culture dated 8/11 14. Eye Culture dated 8/11 15. Throat Culture dated 8/11 16. Wound Culture dated 8/11 17. Sputum Culture dated 8/11 18. Immunization/Vaccination Protocol-Resident dated 10/09 19. Influenza and Pneumococcal Vaccination-Resident dated 10/09 20. [MEDICAL CONDITION] Skin Testing-Employee & Resident dated 1/16 21. Exposure Control Plan dated 1/16 22. Engineering and Work Practice Controls for Bloodborne Pathogens dated 8/13 23. Training on Exposure Control Plan and Bloodborne Pathogen Education dated 8/13 The facility is not annual reviewing and updating policy to ensure effectiveness and that they are in accordance with current standards of practice for preventing and controlling infections. Observation on 12/17/18 at 9:00 a.m. revealed Certified Nursing Assistant (CNA) TT carry a breakfast tray into the room of R#151, who is on Transmission Based Precautions for Extended Spectrum Beta-Lactamase (ESBL) in her urine, without putting on Personal Protective Equipment (PPE). CNA TT sat the tray down on the bedside table and moved the table toward the resident then walked out of the room, put on gloves, reentered the room, and assist with meal set up without washing or sanitizing her hands. During an observation on 12/18/18 at 9:25 a.m. during medication pass on R#232 on Magnolia wing, with Transmission Based Precautions for ESBL in the urine, with LPN UU she sanitized her hands, put on a gown and put a pair of gloves in her hand, gathered meds for R#232, entered the residents room and placed the meds and water on the bedside table and moved the table next to the residents bed. She then turned off the feeding pump, used the control to lower the head of the bed of the resident, then walked around to the bedside table and put her gloves on. She did not wash or sanitize her hands before putting on her gloves. When she finished administering the medications, via the feeding tube, she replaced the feeding, removed her gloves and gown and threw them away in the trash can, raised the head of the bed, restarted the feeding, washed her hands and used the paper towels she dried her hands with to wipe off the bedside table and move it back to the window and exited the room. During an observation on 12/18/18 at 12:55 p.m., during lunch in the rehab unit, revealed CNA GG sanitize her hands and take a tray from the cart and go into a residents room, R#158, who is on contact isolation for [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) in a surgical wound without putting on PPE. During this time a staff member informed the CNA that the resident was gone to [MEDICAL TREATMENT]. During an interview on 12/18/18 at 1:00 p.m. with CNA GG revealed that she should have put on a gown and gloves prior to entering the room of R#158 but stated she just forgot. During an interview on 12/19/18 at 9:00 a.m. with the DON revealed that she spoke with CNA GG and that she expects all staff to use PPE prior to entering a room of a resident on transmission-based precautions. During a medication pass on 12/19/18 at 9:10 a.m. with LPN VV on C-Hall she did not wash or sanitized her hands before administering medication to the resident. After administration and before leaving the room she washed her hands in the resident sink. During an interview on 12/19/18 at 11:15 a.m. with the DON, in her office, she stated she expects the nursing staff to follow the policy on Transmission Based Precautions. She stated when staff see the sign that says Stop and See Nurse the staff know that they lift the sign and the other side will instruct them exactly what PPE is needed for that resident and she expects them to wash or sanitize their hands, put on the appropriate PPE, enter the resident room and take care of their needs, remove the PPE and dispose of it in the room, wash their hands, and exit the room. She stated that she expects nurses who are doing med pass to wash or sanitize their hands, prepare the medication, sanitize their hands, administer the medication to the resident and wash their hands prior to leaving the room. DON stated that she expects the nurse giving medications to follow the transmission-based precaution policy as she previously stated to this surveyor. |
2020-09-01 |