| 24 |
GUAM MEMORIAL HOSPITAL AUTHORITY |
655000 |
499 NORTH SABANA DRIVE |
BARRIGADA |
GU |
96913 |
2017-08-24 |
441 |
F |
0 |
1 |
10C511 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and review of the facility policy MANAGEMENT OF PATIENTS WITH EPIDEMIOLOGICALLY SIGNIFICANT ORGANISMS (E.[NAME]MULTI-DRUG RESISTANT ORGANISMS, METHICILIN RESISTANT STAPH AUREUS, and [MEDICATION NAME] RESISTANT [MEDICATION NAME] (VRE), last revised in (YEAR), the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of diseases and infection. This had the potential to affect all resident in the facility and observation revealed the facility failed to follow policy and procedure to prevent the spread of infection for 2 of 8 sampled Residents (R)1 and R4. Findings include: 1. Interview with Staff Member 3 who is the assigned infection control nurse for the skilled nursing unit on 8/23/17 at 8:55 a.m., revealed that she did not have an infection control log to show which residents have infections, where the infection is located, symptoms, any tests that were done, or antibiotics given. The facility also was unable to provide any documentation to show tracking and/or trending of infections. Review of the facility policy titled, MANAGEMENT OF PATIENTS WITH EPIDEMIOLOGICALLY SIGNIFICANT ORGANISMS (E.[NAME]MULTI-DRUG RESISTANT ORGANISMS, METHICILIN RESISTANT STAPH AUREUS, and [MEDICATION NAME] RESISTANT [MEDICATION NAME] (VRE), last reviewed in (YEAR), revealed that the purpose of the policy was to provide guidance on preventing the spread of epidemiologically significant organism infection transmission from patients to other patients, personnel and visitors. Section 4 speaks to personal protective equipment with the following guidelines; a. Gloves: wear gloves upon entry for all interactions i. Minimize touch contamination with use of gloves. ii. Remove gloves and wash hands in between procedures or after contact with material that could contain high concentrations of the MDRO (multi drug resistant organisms). iii. Remove gloves and wash hands prior to leaving the patient's room. b. Isolation Gown: i. Gowns much be donned upon entry for all interactions. ii. Remove gown before leaving the patient's room and immediately wash hands with an antiseptic soap or a waterless antiseptic agent. 2. The facility uses an educational handout for the patient/family/visitors. There are two copies, one is kept by the facility and the other is given to the patient. The form notes, In the hospital, we work to prevent the spread of germs that can cause infections. This is both to help patients from getting sicker while they are in the hospital and to prevent any patient's illnesses from spreading to the staff and other patients. If you are placed in isolation, it is because you may have a germ that can spread easily in the hospital setting. In some cases, you may be contagious even if you do not feel sick. An isolation sign will be placed on your door asking all who enter to wear gloves and gowns when they enter your room. Instructions: Everyone entering must wear gloves and an isolation gown prior to room entry. Visitors are RESTRICTED. Watcher/support person is required to wear an isolation gown and gloves upon room entry and for the duration of stay in the patient's room. A watcher/support person should not be present if they are sick. Everyone (Staff/Watcher/Support Person) must hand wash or use alcohol hand rub before entering and before leaving the room. The patient and family sign this form noting that they have been given education regarding instructions for isolation. Observation of a visitor for Resident 1 on 8/22/17 at 1:55 p.m., revealed that the visitor stopped at the nursing station and then went to the resident's room. Staff member 13 was not aware of who the visitor was, and went to ask, noting that it was a family member. The visitor put on gloves and entered the room. When questioned by the surveyor as to the visitor not wearing a gown, Staff Member 13 said that visitors only have to wear gloves if just talking to resident. Staff Member 13, went to the resident's room to talk to the visitor and came back to the nursing station and said that the visitor said she would only talk with the resident. Observation also noted that the visitor did not wash her hands or use an alcohol hand rub prior to entering the room. 2. A physician's order dated 4/21/17 was in place for R4 to be placed on contact isolation precautions related to [DIAGNOSES REDACTED], from her buttocks to her groin. A care plan, dated 4/22/17, identified that R4 was on contact isolation and the clinical staff would monitor staff, resident and family members for compliance, with proper hand washing, proper donning (putting on) of gown and gloves. An observation was conducted outside of the room of R4 on 8/22/17 at 7:30 a.m. Staff Member 19 was observed in the resident's room, without a gown and gloves, and had placed the resident's meal tray on her bedside table. It was also during this observation, that the resident was served her meal on a regular tray and dishes. These items were not disposable. This staff member was observed to wash her hands prior to exiting the resident's room. The staff member was interviewed immediately after this observation and Staff Member 4 said that there were no gowns present in the drawers. The drawers sat on the outside of the resident's room. An observation was made of the contents of the drawers and there were blue gowns present. During this observation period, there was a sign located on the outside of R4's room which stated the following, .Everyone entering must wear gloves and an isolation gown prior to room entry . A second observation was made on 8/22/17 at 7:50 a.m. with Staff Member 4. Staff Member 4, entered the room of the resident without donning a gown or gloves. When the staff member was asked why she did not don a gown and gloves, she stated that she did not touch the resident. An interview was conducted with Staff Member 18 on 8/22/17 at 9:31 a.m. Staff Member 18 stated that any time a resident is on contact isolation, they should be served on disposable trays and dishes. Another interview was conducted with Staff Member 18 on 8/22/17 at 9:40 a.m. Staff Member 18 stated that staff should follow the guidelines as identified on the contact isolation sign located on the outside of a resident's room. Staff Member 18 said anytime a staff member enters an isolation room, they should don a gown and gloves. An interview was conducted with Staff Member 6 on 8/22/17 at 10:01 a.m. Staff member 6 said that the kitchen has not served any resident who is on contact isolation with disposable trays. The dishwasher was out of service at the time of the survey. Dishes were being washed by hand. |
2020-09-01 |