| 12671 |
ALEGENT HEALTH IMMANUEL FONTENELLE HOME |
285085 |
6809 N 68TH PLAZA |
OMAHA |
NE |
68152 |
2010-03-03 |
441 |
E |
|
|
9OFY11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F441 LICENSURE REFERENCE NUMBER-12-006.17B-Prevention of Cross-Contamination LICENSURE REFERENCE NUMBER-12-006.17D -Hand washing Based on observation, record review and interview the nursing staff failed to follow infection control practices during the provision of treatment and services related to hand washing and gloving during personal hygiene cares for incontinent residents, administering fluids per Gastrostomy tube, handling and transporting soiled linens and disinfecting the glucose meter. The total samples of 24 residents within the nursing facility census of 152 were reviewed. Findings are: A. Review of the Alegent Health Skills Demonstration, revised 01/06/10, requires Hand Washing, Item 3. Lathers all surfaces of fingers, hands and wrists, producing friction for at least 20 seconds; And Item 4. Can state that the minimum length of time to wash hands is 20 seconds. B. Review of GLOVE INFORMATION HEALTH CARE WORKERS, Occupational safety and Health Administration updated Blood borne pathogens Standard, effective April 2001: in part states: *it is crucial for Health Care Worker ' s (HCW ' s) to wash hands following glove removal when hands are visibly soiled. Hands should also be washed when the integrity of the gloves has been compromised (torn, etc.) during use. In the absence of visible (or any perceived) contamination of hands, hand hygiene with alcohol hand rubs is appropriate, following glove removal. Gloves should also be changed any time the healthcare worker switches from contaminated to clean tasks. C. On 3/2/2010, from 8:15 to 9:10 A.M., observation of both NA (Nurse Aide) F and E during the provision of personal hygiene cares for Resident 1 revealed both NA (Nurse Aide) F and E contaminated their hand gloves with stool while attempting to remove the resident ' s brief. NA-F commented, " I ' m contaminated " and held both hands up off the resident. While NA-E continued to hold the resident over by the buttock covered with stool and stool contaminated hand gloves, NA-F attempted to wipe the stool off the right buttock with a wash cloth contaminated with stool. NA-F attempted to reposition the resident with the contaminated gloved hands. A suggestion was made for the NA ' s to start over. Both NA ' s removed the contaminated gloves, completed hand washing for 4-6 seconds and donned clean gloves. NA-E completed catheter care. Using the same gloves, NA-E started to put the barrier creme on the buttocks. NA-E was gently reminded the gloves were the same gloves used for catheter cares. NA-E completed hand hygiene and donned clean gloves. NA-E put underarm deodorant on, under Resident 1 ' s arms, with out cleansing the under arm axilla first. D. *1.On 3/1/10 at 4:05 P.M. observation revealed the LPN (License Practical Nurse) Nurse-A failed to complete hand washing hygiene after the removal of gloves upon the completion of Gastrostomy cares and administration of oral medications for Resident 7. *2.On 3/2/10 from 9:20 to 9:45 A.M. observation of Resident 7 ' s personal hygiene cares revealed NA-D failed to perform hand hygiene prior to donning clean gloves to provide the personal cares. After placement of the bed pan, NA-D removed the gloves and performed hand washing for 6 seconds. NA-E arrived to assist NA-D. NA-E completed hand washing in 9 seconds. At 9:25 A.M. NA-E removed the bed pan, emptied and rinsed it, and changed gloves with no hand hygiene and or alcohol rub. NA-E left the resident ' s room and returned to get the wheel chair ready for transfer and washed hands for 4 seconds. After NA-E applied Barrier Creme to the abdominal fold, removed the contaminated gloves and performed hand washing for 6 seconds. *3.Interview with NA-E and NA-D confirmed the hand washing should be 20 seconds. *4.NA-D washed hands for 6 seconds and donned gloves. The NA placed all soiled linens in a plastic bag and the trash into a separate plastic bag. Both bags were tied with the contaminated gloves. NA-D proceeded to pick up 3 plastic bags filled with soiled items and preceded to carry them out of Resident 7 ' s room. On the way to the soiled utility room, NA-D stopped, walked into another resident ' s room and pick up 2 additional plastic bags with soiled items in them. NA-D continued to the soiled utility room to deposit the 5 plastic bags. After placing the bags in the utility room, NA-D picked up a can of bleach wipes from the carrier bag hanging on a Hoyer lift in the hallway, returned to Resident 7 ' s room and wiped down the mattress cover that had been contaminated with urine, wiped down the mechanical lift in the resident ' s room, removed the contaminated gloves, performed no hand washing, left the room to place the bleach wipes on the lift in the hallway, went to the linen closet, gathered clean linens, returned to the resident ' s room and placed the linens on the mattress at 9:55 A.M. NA-D performed hand washing for 10 seconds. E. *1. On 03/02/2010 at 7:00 A.M. observations revealed the Medication Aide (MA) -C performed an Accu-Check on Resident 30. MA-C failed to perform hand washing prior to donning gloves to handle the glucose meter. The glucose meter was carried into Resident 30 ' s room, placed on the surface of the chest of drawers. After using the Lancet and obtaining the drop of blood for the glucose strip, MA-C cleansed the blood from the finger, removed the strip from the meter, deposited the needle into the sharps container in the bathroom at the same time carrying the equipment in the gloved hand. MA-C ran the menu to punch in the message for the end result of the procedure, " informed nurse " . MA-C removed the gloves in the resident ' s bathroom and returned the glucose meter to the top of the medication cart. No cleansing of the meter had been performed. *2. On 03/02/2010 at 7:18 A.M. observations revealed LPN-Nurse-B donned gloves taken from the top of the medication cart. Resident 30 ' s 2 different types of insulin had been prepared in 2 separate syringes. Nurse-B took the prepared insulin shots and 2 antiseptic wipes into Resident 30 ' s room to be given. The resident had raised the clothes on the abdomen to receive the shots. Nurse-B cleansed the first area of skin to receive the first insulin shot and placed the antiseptic wipe on its packaged container on the resident ' s bedside stand. After administering the first shot, Nurse-B took the same antiseptic wipe used for the first skin cleansing and cleansed the second skin site to receive the second shot. The syringes were placed into the sharps container in the bathroom and Nurse-B left Resident 30 ' s room wearing the same gloves. After walking a distance down the hallway, Nurse-B removed the contaminated hand gloves and carried them back to the medication cart, placing the gloves into the trash container on the medication cart, and then used hand gel to cleanse hands. Upon completion of the procedure, interview with Nurse-B related to no hand washing and no removal of contaminated gloves replied " yes, I did " , and confirmed that hand hygiene had not completed. F. Record review of a Face Sheet revealed that Resident 9 was admitted to the facility on [DATE]. Record review of Resident 9's MDS dated and signed as completed on 10/01/2009 revealed that Resident 9 had an indwelling catheter ( a tube placed into the bladder). Further review of the MDS revealed that Resident 9 had the [DIAGNOSES REDACTED]. Observation on 3/3/2010 at 8:10 AM revealed NA I and CMA G entered Resident 9's room washed their hands and donned gloves. NA I began to cleanse Resident 9's peri-area cleaning in-between the abdominal folds and groin. CMA G began to cleans the indwelling catheter, cleaning from the insertion site outward. CMA G completed the cleansing and without changing the soiled gloves touched Resident 9's blanket, hair, clean adult brief and Resident 9's legs. CMA G then removed the soiled gloves and used hand sanitizer. An interview with CMA G was conducted on 3/03/2010 at 8:45 AM. During the interview, CMA G confirmed that the gloves had not been changed. G. Observation on 3/01/2010 between 6:45 AM and 7:25 AM of glucose monitoring via a Accu-Chek ( a procedure of checking a residents blood sugar level by sticking the resident finger with a lancet and placing a drop of the residents blood onto a strip that has been inserted into the Accu-Chek machine) revealed LPN H calibrated the Accu-Chek machine at the medication cart. LPN H took the Accu-Chek machine into Resident 26's room. LPN H placed the machine onto Resident 26's bed and donned gloves. LPN H stuck Resident 26's 3 finger on the right hand and placed a drop of blood onto the strip that had been placed in the Accu-chek machine. LPN H removed the strip after obtaining the results and held it in (gender) gloved hands. LPN H picked up the Accu-Chek machine and without removing the soiled gloves or handwashing returned to the medication cart and placed the meter on top of the cart. LPN H removed the soiled gloves and picked up the soiled Accu-Chek machine and obtained the reading for documentation into the residents record. The Accu-Chek machine had not been cleansed before or after being used for Resident 28. LPN H calibrated the same uncleansed Accu-Chek machine and went into Resident 28 room. LPN H placed the Accu-Chek machine onto the residents bed with out a barrier in betweenthe meter and bed, donned gloves and stuck Resident 28's finger with a lancet and placed the drop of the resident's blood onto the strip that had been placed into the meter. After obtaining the results, LPN H removed the strip, gave the resident a cotton ball for the finger that had been stuck to wipe the blood off the finger. LPN H holding the used strip, the Accu-Chek machine, removed the soiled cotton ball and returned to the medication cart. LPN H placed the uncleaned meter on top of the medication cart and removed the soiled gloves with the used strip and cotton ball inside of them. LPN H picked up the soiled meter with bare hands, obtained the reading for documentation and placed the soiled meter back on top of the medication cart. The meter had not been cleansed before or after use for Resident 25. LPN H without handwashing obtained a vial of insulin to administer insulin to Resident 28. LPN H administered the insulin to Resident 28 in (gender) room. LPN H removed gloves that had been worn and completed handwashing for 24 seconds. LPN H returned to the medication cart, picked up the uncleansed Accu-Chek machine, calibrated it for use and went into Resident 27's room. LPN H placed the meter onto Resident 27's bed side table. No barrier had been placed between the table and meter. LPN H donned gloves, stuck Resident 27's second finger on the left hand with a lancet, placed the drop of blood onto a strip that had been placed into the meter. After obtaining the results, LPN H removed the gloves and picked up the soiled meter with bare hands and returned to the medication cart, records the results into the residents record and prepares insulin to be administered to Resident 27. LPN H hands had not been washed or the Accu-Chek machine cleansed before or after use. An interview with LPN H was conducted on 3/01/2010 at 7:25 AM. During the interview, LPN H was asked when should the Accu-Chek machine be cleansed? LPN H stated " before and after each resident". LPN H confirmed that the Accu-Chek machines had not been cleansed before and after use with Residents 26, 27 and 28. LPN H further confirmed that handwashing had not been completed as identified above. On 3/01/2010 an interview with the DON was conducted related to the Accu-Chek meters. During the interview, the DON stated that the expectation is that the Accu-Chek machines are to be cleansed in between each resident use. Record review of the facility policy and procedure titled Blood Glucose- Accu-Check Inform System effective date 7/08 and reviewed on 8/09 revealed the following: -#6 A. Normal infection control guidelines are exercised when handling laboratory reagents. -7B,#1. Cleaning should be preformed dailywhen running the daily quality control, when there is visible blood on the Accu-Chek... H. On March 1, 2010 at 10:45 AM, observation was made of Resident 12 receiving help with toileting cares. Resident 12 is a two person pivot to transfer. When needing assistance with transferring off the commode to the wheelchair, Nursing Assistant J opened door to hallway and asked LPN K for help transferring Resident 12. LPN K entered room and donned gloves without washing hands. LPN K assisted Resident 12 on one side lifting under Resident 12 ' s arm. As Resident 12 was finishing being lowered to the wheelchair, the unit telephone (which was located in LPN K' s pocket) began to ring. LPN K reached into the uniform pocket, with gloved hand, and pushed the talk button on the phone, putting the phone in the crook of LPN K's neck and began talking. While still talking, LPN K removed gloves and threw them in the trash and turned water on to wash hands. LPN K put hands under water and then removed in less then 2 seconds, using no soap. LPN K used paper towels to dry hands and threw them in trash while still talking on phone as walking out the door. |
2014-04-01 |