cms_GU: 83
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 83 | GUAM MEMORIAL HOSPITAL AUTHORITY | 655000 | 499 NORTH SABANA DRIVE | BARRIGADA | GU | 96913 | 2012-01-26 | 441 | G | 0 | 1 | J2NN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection, when the facility did not prevent the development of infections for 3 of 15 residents (sampled Resident 6, 3, and unsampled Resident 14.); failed to provide adequate supplies of PPE to prevent cross contamination where seven resident rooms had contact isolation precautions in place; Staff inconsistently follow infection control techniques; and the infection control designee was not trained for infection control management nor given the time to conduct infection control assignments and the facility did not have an effective tracking and monitoring system to ensure the vaccination status of all residents. Findings include: 1. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a gastrostomy tube ([DEVICE]) for feeding and a urinary catheter for elimination. The resident required total assistance for activities of daily living (ADLs). The resident's family member was with the resident most of the time. During the initial tour on 1/23/2012 at 4:30 PM, Resident 6 was observed lying in bed. Her family member was sitting next to the resident's bed without wear Personal Protective Equipment (PPE). When asked what the facility had taught him about the use of PPE, and he looked at the sign, he said he had not noticed the sign and though he did notice the staff usually wore a yellow gown and gloves, they told him he did not need to, just to wash his hands frequently. He stated the staff taught him to feed the resident through the feeding tube and how to clean the resident's privates, and how to change the dressing on the wound. When he did those things he stated he wore gloves, but not a gown. The resident stated he did interact with other residents and visitors and sat in common areas of the facility. There was a sign on the resident's door indicating the resident was on: Contact Precautions Isolation an Standard Precautions; Gown and Glove When Entering (these are called (PPE)); Clean hands before entering room and upon exiting, wash hands thoroughly for at least 15 seconds or use Alcohol hand foam. A staff member was seen exiting the resident's room wearing a yellow gown, she took off the gown and hung it on a pole attached to the drawers where the clean PPE were outside the door of the room. Then she reentered the room to wash her hands in the resident's bathroom. The resident's urinary catheter bag was on the floor. During observations of care provided on 1/24/2012 at 1:30 PM, a licensed nurse (LN) and a certified nursing assistant (CNA) donned PPE then went into Resident 6's room to provide care. The resident was positioned on her right side. The CNA removed the resident's soiled brief. The urinary catheter bag was attached to the right side of the bed, causing the catheter tube to pull from the resident's urethra over the stool and down to the collection bag. Neither the LN nor the CNA moved the collection bag to the left side of the bed, nearer to the resident and out of area where the staff were working. The CNA used a gloved hand to clean the resident while pouring water over the perineum and the catheter tubing- spreading the stool over the entire perineum including the opening of the urethra, which increased the risk of urinary infection. After the area was cleaned the LN removed the dressing from a Stage 4 pressure ulcer on the resident's sacrum. She cleansed the wound, and dressed it as ordered by the physician; however when she tried to secure the dressing, she taped the lower end of the dressing very near the anus and the tap would not stick. The LN stuffed extra gauze under the tape, to prevent any stool from getting in the wound. The staff stated they had completed the resident's care. Resident 6's heels were covered with socks and heel protectors (a foam bootie). The surveyor asked to see the resident's heels. The right heel had a black circular pressure ulcer with reddened area surrounding the ulcer. The measurements were 4.0 cm x 2.0 cm. The wound bed could not be visualized as it was covered with hard black necrotic (dead) tissue termed Eschar. No treatment was provided for the heel pressure ulcer. The LN and CNA removed their gloves, washed their hands then exited the room where they removed their gowns. The CNA threw away the gown and the LN hung her gown on the pole attached to the drawers where clean PPE was stored. When asked about the method of cleaning the resident, the CNA stated We do not have enough wash cloths to go around. When asked about the catheter pulling the CNA and the LN stated, We should have moved it to the other side. When asked why she hung the soiled gown on the pole outside the resident's room, the LN stated they run out of gowns if they throw them out each time. Review of the record revealed the following: A summary of the review of the staff and physician notes revealed the following: 10/22/2011 - Admission; 10/28/2011 - minimal amount of drainage around the feeding tube; 10/29/2011- greenish discharge from the feeding tube site. On 11/9/11- staff collected C&S from [DEVICE] site results showed infection with MDROs- [DIAGNOSES REDACTED] pneumoniae and Pseudomanas aeruginosa; On 11/8/2011 LN noted there was pus at the Peripherally inserted central catheter (PICC) site on the resident's right upper arm. In the physicians notes and orders dated 11/30/2012 the MD ordered RN to remove the PICC and send the tip for C&S. The physician also ordered IV fluids for two days. However there was no order for replacement of the PICC or to insert any other type of IV. On 12/5/2012 and MD ordered at 9 PM, Please remove PICC now- send cath (catheter) tip for C&S. Lab result showed C&S collected 12/6/11 with PICC site infection with MDRO - [DIAGNOSES REDACTED] pneumonia. During an interview on 1/24/2011 at 3: 35 PM, when asked about the infection of the PICC site and why the PICC was removed five days after the MD's order, a LN familiar with the patient stated the infection was bad at the site and there was pus all around it. The MD ordered antibiotics on the same day and (the LN on duty) was afraid to remove it (the PICC). Review of the laboratory reports also revealed the following time lines of infections for Resident 6: [DEVICE] site - staff collected Culture and Sensitivity (C&S) on 11/9/2011 results showed infection with MDROs- [DIAGNOSES REDACTED] pneumoniae and Pseudomanas aeruginosa; Two urinary tract infections (UTI) collected C&S 11/16/11 with Escherichia coli (E.coli- an organism found in feces) and 12/6/11 with Pseudomanas aeruginosa; and Peripherally inserted central catheter (PICC) site infection C&S collected 12/6/11 with [DIAGNOSES REDACTED] pneumonia. The sacral wound was infected 12/29/2011 with two of the bacterium found in three other sites of the body. A swab sample of the sacral wound drainage was collected on 12/29/2011 source: deep wound sacral pressure ulcer Stage 4. A C&S final results dated 1/3/2012 showed infection with four multi-drug resistant organisms (MDROs): Pseudomonas aeruginosa, Cirtobacter freundii, Acinetobacter baumannii, and [DIAGNOSES REDACTED] pneumoniae. Two of these organisms, [DIAGNOSES REDACTED] pneumoniae and Pseudomanas aeruginosa, were found in the infections of the three sites listed above. The resident had been on numerous antibiotics since admission: 11/ 9/2011 -[MEDICATION NAME] mg via feeding tube daily for two weeks. 11/19/2011 - [MEDICATION NAME] 1 Gram (gm) IV daily for 7 days; 12/8/11 [MEDICATION NAME] 3.375 mg IV every 12 hours for two weeks and [MEDICATION NAME] 500 mg IV daily for 2 weeks; 12/10/11 Impenem 250 mg IV every 12 hours for 7 days and Amikrein 240 Mg IVPB every 24 hours for three days. 12/29/11 [MEDICATION NAME] 3.375 gms in 50 ml of normal sa IV every 12 hours for 7 days; 12/30/11 [MEDICATION NAME] 1 gm IV daily for 7 days; and 1/2/12 [MEDICATION NAME] 1 gm IV every 12 hours for 10 days and Imipenem 250 mg IV every 6 hours for six weeks. 2. During a tour of the residents rooms with the acting administrator and the head nurse on 1/26/2012 beginning at 8:45 AM, the following was observed: room [ROOM NUMBER] a contact precaution sign for a resident infected with Clostridium Difficile (C.Diff)- the sign instructed those entering and exiting to wear PPE and to wash hands with soap and water. There was a yellow gown hanging on the pole attached to the drawers where the clean PPE were located outside the resident's room. room [ROOM NUMBER] the resident was infected with MDRO infections; room [ROOM NUMBER] the resident was infected with Methicillin Resistant Staphylococcus Aureus (MRSA); room [ROOM NUMBER] the resident was infected with [DIAGNOSES REDACTED] (flesh eating bacteria) and C.Diff. The contact precaution signs outside each of these rooms were the same, Contact Precautions Isolation an Standard Precautions; Gown and Glove When Entering (these are called Personal Protective Equipment (PPE)) Clean hands before entering room and upon exiting, wash hands thoroughly for at least 15 seconds or use Alcohol hand foam. On 1/26/2012 at 8:50 AM, room [ROOM NUMBER] the resident was infected with MRSA. There was an occupational therapist (OT) working with the resident in the room. The OT had on a yellow gown that was loosely tied at the neck and not at the waist potentially exposing parts of the OT's personal clothing to the MRSA organism. A CNA exited the room, removed her yellow gown and hung it on the pole attached to the drawers where the clean PPE were located outside the resident's room; she then washed her hands. room [ROOM NUMBER] - the resident was infected with MRSA - the contact precaution sign indicated visitors did not need to wear PPE. The assistant administrator and the head nurse stated the resident had a wound so the visitors did not need to wear PPE. room [ROOM NUMBER] - the resident was infected with MDRO, and had a different contact precaution sign. room [ROOM NUMBER] - the resident was infected with MRSA and had the following sign: Contact Precautions Isolation an Standard Precautions; Gown and Glove When Entering (these are called Personal Protective Equipment (PPE)) Clean hands before entering room and upon exiting, wash hands thoroughly for at least 15 seconds or use Alcohol hand foam. During interviews 1/26/2012 beginning at 8:45 AM, When asked why the staff hung the contaminated yellow gowns on the pole outside the residents' rooms that had isolation precautions, the acting administrator and the head nurse stated the facility had limited resources. The acting administrator stated if they threw away the gowns after each use they would run out in one day. He stated the hospital administration was aware of this problem, however no changes had been made. When asked why the LN continued to instill IV fluids into an infected PICC site, the acting administrator stated the LN should have removed the PICC the first time the MD order the removal or obtained a clarification order to continue IV fluids via the PICC site or to insert a peripheral IV . 3. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hospital history and physical record dated 1/8/12 revealed the resident was admitted due to sepsis Recent admission with urinary tract infection, dysuria and infected left leg. Urine cultures showed Escherichia (E.) Coli and leg wounds with heavy growth of pseudomonas aeruginosa (1/17/12). Review of the Patient Progress Notes record dated 1/12/12 revealed the left leg wounds were debrided. On the same day, the physician ordered wound care daily alternate wet to dry with [MEDICATION NAME]. On 1/23/12 at 3:10 PM, during the initial tour, a posting outside the resident's room stated Contact Isolation. Resident 3's left lower leg dressing was observed soaked with bright red drainage. The licensed nurse stated that the physician has just changed the resident's leg ulcer dressing at the bedside. The licensed nurse went inside the resident's room without wearing an isolation gown. With a pair of gloves on, the licensed nurse repositioned the resident's leg to check the dressing moderately saturated with fresh blood. She changed her gloves, and without washing her hands, the licensed nurse proceeded to get a new disposable pad from the resident's closet. She placed the disposable pad under the resident's left leg to protect to line the resident's linen be saturated with the drainage. She then checked on the resident who was pointing to her disposable diaper. The resident is a known deaf and mute to the facility staff. The licensed nurse continued to check on the resident's diaper for tightness without changing her gloves. Review of the resident's plan of care showed no evidence of precautions to be taken while resident is on contact isolation. 4. On 1/23/12 at 3 PM, during the initial tour non-sample Resident 14's room had a posting, Contact isolation A licensed nurse was observed inside the resident's room wearing gloves and no isolation gown. Interview with the nurse revealed that she was assisting and cleaning the resident's face to wipe off the sputum. When asked what kind of infection the resident has, the licensed nurse stated the resident has methicillin-resistant staphylococcus aureus (MRSA) of the sputum. Review of sputum culture dated 7/17/11 revealed heavy growth of MRSA. Interview with the charge nurse on 1/25/12 revealed that the physician does not want to re-culture. Review of the resident care plan showed no evidence of precautions to be taken while the Contact Isolation is still being enforced. On the same day and time, Resident 14's Foley catheter drainage bag was also observed lying on the floor. There was no effort to get the bag off the floor in the presence of a licensed nurse in the room. 5. Interview with nursing administrative staff revealed that the facility did not have a qualified infection control coordinator responsible for investigating, controlling, and preventing infections in the facility. Review of the facility's infection control manual revealed several duties of the infection control representative including the ability to demonstrate knowledge of complete infection control process in the healthcare setting; demonstrating understanding of standard and isolation precautions set forth by the CDC; attending continuing education program and maintaining current knowledge of all aspects of infection control; demonstrating knowledge of microbiology and modes of transmission of disease entities, conferring with staff nurses on a regular basis to determine occurrence of healthcare associated infections; and communicating infection control activities to the infection control practitioner at the hospital. During an interview on 1/25/12, an administrative staff member stated that the facility's infection control coordinator was a licensed nursing staff who worked full-time on the evening shift (3:00 PM - 11:00 PM). When asked if the number of hours allocated for infection control duties and responsibilities by the staff could be determined, the administrative staff stated that the time was not captured because the licensed staff, when regularly scheduled, provided direct patient care. The administrative staff added that the licensed nursing staff could not work during her days off to conduct infection control activities because overtime pay was not being authorized. In the same interview, the administrative staff stated that the facility's infection control coordinator did not have training in infection control but that she consulted with the hospital infection control coordinator on a regular basis. When asked if meeting minutes were maintained during these consultation, the staff stated that he was not aware. During a separate interview on 1/25/12, the hospital's infection control coordinator stated that there were regular consultations between her and the facility's infection control representative. When asked if documentation was maintained detailing when these consultations occurred and what topics were discussed, none was provided. 6. The facility did not have an effective tracking and monitoring system to ensure that the vaccination status of residents in the facility could be determined so that the influenza and pneumococcal vaccines could be offered. In addition, the facility did not have policy and procedures that included provisions required under 483.25(n)(1)&(2). (Cross-refer to F334.) | 2017-01-01 |