cms_MT: 4870
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4870 | PIONEER MEDICAL CENTER LTC | 275139 | 301 W 7TH AVE | BIG TIMBER | MT | 59011 | 2014-02-27 | 441 | F | 0 | 1 | EV5411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record reviews, the facility failed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection for all residents. A resident's catheter bag was observed multiple times dragging on the floor; the separation door in the laundry room was propped open and the potential for cross contamination during laundry procedures was present; and the staff failed to follow proper hand washing procedures during care for 5 (#s 2, 10, 11, 13, and 14) of 14 sampled and supplemental residents. Findings include: 1. The surveyor observed resident #2's catheter bag dragging on the floor on 2/24/14 at 5 p.m., 2/25/14 at 11:15 a.m., 2/26/14 at 4:55 p.m. and 2/27/14 at 8:15 a.m. Staff member A, DON was interviewed on 2/27/14 at 8:17 a.m. and stated that if a catheter bag is dragging on the floor, it is a problem, and that it could "get snagged on something and tear." 2. On 2/25/14 at 10:34 a.m., the separation door between the soiled linen room and the washing room was found propped open. Staff member G, a laundry aide, showed the process of sorting, washing, drying and folding the linen and residents' clothes. The staff member put on a pair of purple gloves to show how the soiled laundry is separated. While putting on her gloves she stated that the gloves are for the soiled linen side only. While showing the soiled linen separation procedure the staff member touched a blanket that had been used for a resident's bed. She then opened the lid to the contaminated/potentially hazardous linen and showed the procedure for pre-cleaning these articles. She picked up the spray nozzle located in the soiled linen room that would be used after placing the laundry into the wash sink, and showed how the sprayer worked. The observation proceeded to the room that housed the washing machines. A clean lift harness was draped across one of the washing machines. Staff member G continued to open the washing machine and touch the outer surfaces of the washer. The observation proceeded to the clean linen side. The staff member did not remove her gloves nor wash her hands prior to leaving the washing machine room. When asked about how she sorted laundry, staff member G showed the surveyor and proceeded to used her gloved hands to move 3 articles (a white tank top, a purple shirt, and a gray sweatshirt) of clean residents' clothes that were hanging. On 2/25/14 at 11:20 a.m., 1:38 p.m., and again at 2:26 p.m. the separation door in the laundry room was found propped open. On 2/25/14, during the laundry observation, staff member G said that draping the harnesses over the washing machine to dry is the typical practice as it is the only place available to lay them to air dry. During a follow-up interview on 2/25/14 at 2:26 p.m., staff member G was exiting the soiled laundry room with a basket to be washed. She was not observed wearing gloves, clothing protector, or a face shield. She said that the separation door is usually closed, and only open when doing a load of laundry. A sign on the door read, "Door to remain closed and locked at all times." The soiled laundry and bedding policy and procedure was received on 2/26/14 at 8:20 a.m. Procedure #4 reads, "Anyone who handles soiled laundry must wear protective gloves and other appropriate protective equipment (e.g., gowns if soiling of clothing is likely)." 3. Resident #10 was admitted to the facility on [DATE] with the Diagnoses: [REDACTED]. According to her most recent quarterly MDS with an ARD of 2/10/14, the resident required extensive assist during transfers, dressing, toilet use and personal hygiene. On 2/26/14 at 8:17 a.m. morning care was observed for resident #10. Staff member J, CNA, entered the resident's room and donned gloves. She did not wash her hands prior to gloving. She obtained the resident's dentures that the resident was wearing and took them to the sink to brush. Staff member O, a CNA, returned with a new oxygen tank and replaced the empty one. Staff member J, using the same gloves, moved the empty oxygen bottle and wheel chair. Staff member J removed her gloves and left the room, she did not wash her hands. Staff member J returned with a lift to aid the resident. She donned gloves without washing her hands. There were a set of gloves that were placed on the resident's wheelchair and when pushed out of the way by resident J, one of the gloves fell to the floor. She picked up this glove with her gloved hands and placed it on the left foot rest of the wheelchair. The resident was transferred to the toilet. Staff member J removed her gloves, did not wash her hands, and began to make the resident's bed. Staff member O continued with resident care. Mid-way through making the resident's bed, staff member J picked up the gloves that were on the resident's wheelchair, put them on, and finished making the bed and arranging the pillows. Staff member J then removed her gloves and washed her hands. Toward the end of care staff member K, a CNA, entered to finish care. She did not wash her hands upon entering the resident's room. Staff member K moved the resident in her wheelchair, picked up her oxygen cannula and placed it on the resident. Staff member K then washed the resident's glasses, donned gloves and brushed the resident's hair. She then removed her gloves and exited the room assisting the resident in her wheelchair. She did not wash her hands upon exiting the room. On 2/26/14 staff member O and J were interviewed at 9:00 a.m. and 1:30 p.m., respectively. Both said that caregivers should wash hands upon entering and leaving a resident's room and when going from soiled to clean areas. Staff member J also mentioned that caregivers should wash hands and use gloves when handling soiled linens. 4. Resident #11 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 2/25/14 at 9:30 a.m., the surveyor observed staff member H, CNA as she assisted resident #11 to the bathroom. Staff member H placed the walker in front of the resident with wheelchair wheels locked. Staff member H placed her arm under the resident's arm and assisted resident # 11 up into a standing position. Staff member H then assisted her to the bathroom. When resident #11 was in position next to the toilet, staff member pulled down the slacks and the briefs and assisted the resident on the toilet. Staff member H then gloved her hands and cleaned the resident with wipes. Staff member H took off the gloves and then put the briefs and the pants on the resident. Staff member H did not wash her hands when she entered the room, after she removed old brief, and after she finished with resident #11's care. 5. Resident #13 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. On 2/25/14 at 9:40 a.m., the surveyor observed staff member H assisting resident #13 to the bathroom. Staff member H gloved her hands, assisted resident #13 to a standing position, pulled down pants and disposable briefs, and assisted the resident in pivoting to the toilet. When the resident was finished, staff member H cleaned the resident with wipes, assisted with the disposable brief and pulled up the pants. Staff member H did not wash her hands before: assisting resident #13; removing disposable briefs; cleaning resident; and finishing care. 6. Resident #14 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. On 2/25/14 at 9:55 a.m., staff member H assisted resident #14 to the bathroom. Staff member H gloved her hands, assisted in getting the pants down and removed the disposable brief. Resident #14 pivoted to the toilet. When resident #14 finished, staff member H cleaned resident with wipes, then placed clean disposable brief and pants on resident. Staff member H did not wash hands before she assisted resident #14, removed disposable brief, cleaned resident, and finished care. On 2/25/14 at 10:00 a.m., staff members H and I, CNAs were interviewed regarding hand washing procedure and policy. Staff member I indicated that staff may use the alcohol stations in the halls in between residents. Staff member H agreed with staff member I. Staff member H also indicated that the policy was posted in the employee bathroom which she showed the surveyor. The "policy" was a general poster regarding washing hands after using the restroom. Neither staff members H and I were able to state the acceptable hand washing procedure to be used between residents (other than the use of the alcohol base hand rubs in the halls), before gloving, moving from contaminated body site to a non-contaminated body site,and removing gloves. | 2015-07-01 |