cms_GU: 13
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 13 | GUAM MEMORIAL HOSPITAL AUTHORITY | 655000 | 499 NORTH SABANA DRIVE | BARRIGADA | GU | 96913 | 2019-01-30 | 880 | F | 0 | 1 | IS8311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record, review the facility failed to operationalize its infection control program to control to prevent the spread of infections. Failure to always monitor, track, trend, and plot infections within the facility had the potential to contribute to healthcare acquired infections. Additionally, failure to follow the facility policy related to handwashing can also contribute to healthcare acquired infections. Findings include: 1. On 1/29/19, an observation of a pressure ulcer dressing change occurred on Resident 5. The staff completing the procedure were a licensed nurse (LN6) and a certified nursing assistant (CNA4). During the dressing change, the resident defecated 4 times. CNA4 was observed cleaning the bowel movement 3 of the 4 times. After she cleaned the bowel movement she removed her gloves and used a hand sanitizer but did not wash her hands. The facility policy titled hand hygiene was reviewed on that same day. The policy stated in the procedure at item H to, Perform Hand Hygiene after contact with body fluids or excretions mucous membranes non-intact skin and wound dressings. Later that day during an interview with a nursing administrative staff (LN2), she stated that CNA4 should have washed her hands rather than just using the hand sanitizer. On 1/29/2019, during an interview with the infection control prevention (IP1), it was acknowledged that an on-site visit of the contracted laundry service had not been completed within the last year or recertification period. IP1 was also unable to validate if the contracted service was washing facility laundry at the appropriate temperatures and with the appropriate cleaning agents to help prevent the transmission of infectious. 2. During a record review on 1/28/2019 at 1:00 p.m., resident #301 was admitted to facility on 3/24/18 with the [DIAGNOSES REDACTED]. Minimum Data Set (MDS) 14 day assessment completed on 4/7/18 disclosed a Brief Interview for Mental Status (BIMS) score of 14. The facility infection control program failed to monitor, track, trend and document resident #301 for the risk and benefits of receiving an antibiotic therapy as per standard of care and policy. Physician order [REDACTED]. During an interview concurrent with a record review on 1/29/2019 at 2:30 p.m., with the Administrative Staff #2 which is the acting person for infection control program at the facility and Staff #3 both acknowledged that they failed to monitor, track, trend and document on resident #301 antibiotic use upon admission. Staff #2 indicated that upon admission usually it is documented but in this case it was missed. Staff #3 also indicated that usually she monitors the residents that are receiving antibiotics but in this case it was missed on her end also. The facility data collection clinical record disclosed no evidence of the resident receiving any [MEDICATION NAME] mg twice a day from 3/24/18 - 3/31/18 and on 4/15/18 to 4/18/18 resident started on [MEDICATION NAME] 750 mg daily. | 2020-09-01 |