cms_MT: 4276
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4276 | CEDAR WOOD HEALTHCARE COMMUNITY | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2012-12-06 | 441 | F | 0 | 1 | SH3211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on program policy review, staff interview, and observations, the infection control program lacked elements that facilitated analysis of infection incidents, and staff failed to provide care in a manner consistent with accepted infection control standards of practice for 4 (#s 2, 7,11, and 12) of 10 sampled residents and 2 supplemental residents. 1. Infection Control Program On December 5, 2012, the infection control program policies, infection logs, investigations and committee reports were reviewed. - The infection control log and infection reports lacked evidence that standardized infection definitions were used as part of the surveillance system. - The infection control program did not include an antibiotic review to monitor the appropriate use of antibiotics in the resident population. - Infection control records lacked analysis of infection control surveillance data including incidence or prevalence of infections and staff practices or other processes that may be modified to enhance infection prevention and minimize the potential for transmission of infections. - The infection preventionist, the DON, had not received training in infection control. 2. Care concerns a. On 12/6/12 at 6:50 a.m., resident #7 was observed as two CNAs, staff members K and O, provided assistance with activities of daily living. The staff assisted the resident with perianal cleansing after she had a bowel movement using a bedside commode. Staff member O was gloved and cleaned the resident's peri anal area. After cleaning the resident's peri anal area, staff member O continued with the following tasks without sanitizing her hands and changing gloves,? transferred the resident to the bedside using a sit to stand transfer device, removed the transfer sling, repositioned the resident to a supine position in bed, removed the resident's slippers, placed a pillow under the resident's lower legs, folded two bed blankets, and repositioned the privacy curtain. ? At this point, staff member O removed her gloves and washed her hands in the sink. The bedside commode bucket and the peri anal wipes were soiled with stool. b. On 12/3/12 at 4:50 p.m., staff member E, an RN, was observed preparing an insulin injection for resident #12. Staff member E withdrew insulin from a previously opened vial. Staff member E did not clean the rubber cap with an antiseptic wipe. According to Kozier and Erb, a previously opened medication vial must be cleaned with an antiseptic wipe prior to withdrawing medication. ? During an interview on 12/3/12 at 5:00 p.m., staff member E stated she did not always clean insulin vials prior to drawing up the insulin, as the vial of insulin was stored in a clean pill container. During an interview on 12/4/12 at 4:30 p.m., staff member B, the DON, stated the nurse should have used an antiseptic wipe on the medication vial. c. On 12/4/2012 at 10:30 a.m., staff member J was providing morning care to resident #2. Staff member J applied gloves and proceeded to cleanse resident #2's peri anal area. Staff member K handed staff member J a tube of [MEDICATION NAME] ointment. Staff member J took the tube of [MEDICATION NAME] from staff member K with her contaminated gloves. d. On 12/6/12 at 6:50 a.m., staff member L was observed providing care to resident #11. Staff member L rolled resident #11 onto his left side and removed the Attends. Staff member L then set the urine soiled Attends next to a sippy cup on the bedside table. Staff member L then went to the room closet, picked up a washcloth to open one door of the closet, used her still gloved hand to open the other door of the closet, and removed a clean Attends. Staff member L did not remove her gloves or wash her hands before removing the Attends from the closet. Staff member L then put the Attends on the resident, repositioned him in bed, then removed her gloves and washed her hands. Staff member L put gloves on and removed the used Attends from the bedside table and placed it in the garbage, put the soiled linens in a garbage bag and tied both. The CNA took off her gloves, washed hands, then went back to wipe resident #11's nose, positioned the call pad and gave the resident a drink out of the sippy cup that was sitting on the bedside table. Staff member L did not wipe the bedside table after setting the urine soiled Attends on it. ? Based on the CDC Morbidity and Mortality Weekly Report, gloves should be changed during patient care if moving from a contaminated body site to a clean body site. Failure to remove gloves after patient contact or between 'dirty' and 'clean' body-site care on the same patient is regarded as nonadherence to hand-hygiene recommendations. Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings. Morbidity and Mortality Weekly Report: 51(16). ? Kozier, B., Erb, G., Berman, S, & Snyder, S. (2004). Kozier and Erb's Techniques in clinical nursing basic to intermediate skills (5th ed.). New Jersey: Pearson Prentice Hall. | 2016-06-01 |