| 222 |
MIDWEST COVENANT HOME |
285062 |
P O BOX 367, 615 EAST 9TH STREET |
STROMSBURG |
NE |
68666 |
2020-02-27 |
880 |
I |
0 |
1 |
HGI711 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D LICENSURE REFERENCE NUMBER 175 NAC 12-006.18C Based on observation, interview, and record review; the facility staff failed to prevent potential cross contamination by failing to follow contact precautions, failing to perform hand hygiene when indicated, failing to clean equipment used by multiple residents, and failing to ensure the facility policies for infection control, immunizations, and antibiotic stewardship were reviewed annually. The facility staff also failed to ensure that staff followed isolation precautions (the use of gloves, gowns, and hand washing to help stop the spread of germs from one person with a known infection to another) and to ensure that hand hygiene (hand washing) was performed when exiting the room of a resident under isolation precautions before entering the room of another resident. This had the potential to affect all of the facility residents. The facility identified a census of 30 at the time of survey. Findings are: [NAME] Interview with the ICC (Infection Control Coordinator) on 2/27/20 at 1:36 PM revealed the facility had 8 residents who had tested positive for CP-CRE (Carbapenem-resistant [MEDICATION NAME] (CRE) are [MEDICAL CONDITION] that that can cause serious infections and require interventions in healthcare settings to prevent spread according to the CDC (Centers for Disease Control)) and required contact precautions and 2 other residents who were discharged from the facility had also tested positive. Observation of the rooms belonging to Residents 29, 6, 14, 1, 30, 22, 31 and 29 on 2/24/20 at 4:05 PM revealed they had Contact Precautions signs and PPE (Personal Protective Equipment-gowns, gloves, face masks, shoe covers worn to protect the wearer from potential infection) on their doors. Review of the undated facility document Contact Precautions received from the DON (Director of Nursing) revealed the following: Perform hand hygiene before entering and before leaving room, wear gloves when entering room or cubicle, and when touching patient's intact skin, surfaces, or articles in close proximity, wear gown when entering room or cubicle and whenever anticipating that clothing will touch patient items or potentially contaminated environmental surfaces, use patient-dedicated or single-use disposable shared equipment or clean and disinfect shared equipment between patients. Observation of ES-H (Environmental Services) on 2/25/20 at 11:58 AM revealed they were distributing personal clothing to Resident 14 and Resident 1 who shared a room. Contact Precautions were posted on the door. A sign posted on the door read must wear gloves and gown before entering room. ES-H donned gloves and took the clothes into the room, opened a drawer, and placed the clothing into the drawer before closing the drawer. Resident 14 and Resident 1 were present in the room. ES-H did not put a gown on. ES-H then took the gloves off, came out of the room and scrubbed hands with hand sanitizer. ES-H then took clothes to Resident 20, Resident 26, and Resident 7 who did not have contact precautions. ES-H then took clothes to Resident 28 at 02/25/20 at 12:02 PM who had contact precautions and PPE posted on their door. ES-H put gloves on, entered the room, opened the drawer and put the clothes in. ES-H did not have a gown on. ES-H then took the gloves off and used hand sanitizer that was in the dispenser outside the door. Resident 28 was present in the room. ES-H then took clothes to Resident 3, Resident 17, Resident 16, and Resident 21. They did not have contact precautions. On 2/25/20 at 12:06 PM, NA-F (Nurse Aide) took a Styrofoam container of food into Resident 28's room and put it on the wheeled walker platform in front of Resident 28 who was sitting in the recliner then did hand sanitizer and took food to Resident 16 who did not have contact precautions. NA-F was in close proximity to Resident 28 and their belongings and did not have a gown on. On 2/25/20 at 12:09 PM, ES-G brought plastic hangers out of the room belonging to Resident 14 and Resident 1. There was a sign on the door Contact Precautions and PPE. ES-G was wearing gloves and did not have on a gown. ES-G handled the outside of a large white plastic bag marked for CRE hangers with the gloved hands, placed the hangers in the bag, then went back into the room and discarded the gloves. The bag was hanging on the end of a rolling clothes rack that had personal clothing on it that was out in the hall. Resident 14 and Resident 1 were present in the room. At 2/25/20 at 12:10 PM, ES-G had gloved hands and brought hangers from Resident 29's room and placed them in the bag marked for CRE hangers by handling the outside of the bag with the gloved hands. Resident 29 also had a sign on the door Contact Precautions and PPE. ES-G had gloves on and no gown. Resident 29 was present in the room. ES-G then proceeded to push the cart down the hall. The clothes were touching ES-G's smock. ES-G then took clothes into Resident 4's room on 2/25/20 at 12:15 PM then into Resident 2's room. Resident 4 and Resident 2 did not have Contact Precautions on their door. ES-G brought the hangers out of Resident 2's room and hung them on the rack. On 2/25/20 at 12:16 PM ES-G then took clothes in to Resident 5 and Resident 25. Their clothes had also been touching ES-G's smock. On 2/25/20 at 12:17 PM the bag marked for CRE hangers was touching the clothing belonging to Resident 27 and Resident 24 who did not have contact precautions. ES-G was also observed using bare hands when putting the clothes into the closets. On 2/25/20 at 12:19 PM ES-G hung a T shirt on the handrail outside Resident 6's door and it was touching the floor. On 2/25/20 at 12:20 PM ES-G donned gloves and took the T-shirt into Resident 6's room then brought hangers out and put them in the bag marked for CRE hangers by handling the bag with the same gloves. On 2/26/20 at 8:15 AM NA-F was observed carrying a pile of linens (sheets, pillowcases) down the hall up against their uniform. NA-F took the pile of linens into Resident 5's room and put some of the linen on the bed which was stripped. NA-F then took the remainder of the linens still carrying them up against their uniform into Resident 4's room. Interview with LHS (Laundry Housekeeping Supervisor) on 02/27/20 at 11:37 AM revealed the facility staff were supposed to be leaving the hangers in the rooms of residents who have contact precautions until they found a proper procedure for sanitizing them before they brought them out of the room. LHS confirmed they were looking for a disinfectant they could use the clean the hangers. The LHS revealed the facility staff should not be touching the resident clothing to their own clothing when they are passing clothing. If a clothing item fell on the floor or touched the floor the staff should have taken it back to the laundry to wash it. The LHS confirmed that the observations with laundry deviated from their expectations. Review of the undated Policy for Passing linens revealed no documentation of clothing not touching the staff clothing or items should be re-laundered if dropped on the floor or touch the floor. No documentation that staff should not be taking the hangers out of the rooms who had residents in isolation/contact precautions. There was also no documentation that staff should not be taking the same linens from room to room. Review of the facility policy Hallway Policy dated 3/7/2017 revealed the following: Linen carts-load your cart, pass linen and put cart away. B. Observation of the facility bath house on 02/26/20 at 1:52 PM revealed a Penner Cascade jetted tub with a lift chair. NA-E with the DON (Director of Nursing) present proceeded to clean the tub. The DON said they were done with baths for the day so they used a different cleaning procedure as all of the residents used the tub and the residents with CRE received the last baths of the day. NA-E set a timer for 10:45 seconds, dispensed the disinfectant in about 1 1/2 gallons of water into the bottom of the tub, then started wetting the surfaces. Everything was finally wet with 8:47 left on the clock. NA-E then proceeded to use a brush to scrub the tub with Penner disinfectant on the inside of the tub. NA-E said they cleaned the inside of the tub with the Penner disinfectant that was dispensed into the bottom of the tub and NA-E used a spray bottle of the Penner disinfectant the keep the surfaces wet. NA-E said the tub surface had to stay wet with the Penner disinfectant for 10 minutes. NA-E said they would use MicroKill wipes to clean the outside of the tub. NA-E did not put the sprayer or the spray hose into the tub and clean it. NA-E focused on the left side of the tub and did not consistently keep the right side of the tub wet. NA-E only scrubbed the underside of the lift seat that was in the tub 3 times. NA-E did not run the jets on the tub. NA-E said they did the procedure twice so after the 10 minute timer went off, NA-E started over again. This time NA-E put the sprayer into the tub and put the disinfectant on it with the scrub brush but NA-E did not spray the hose on the outside of the tub with the disinfectant. NA-E did not have the sprayer hose wet with disinfectant and the surfaces of the tub were not wet the full 10 minutes. NA-E demonstrated where the disinfectant came out of the floor of the tub, not the jets. NA-E said they did not run the jets when cleaning the tub. At 2:15 PM the DON said they don't have to run the disinfectant through the jets. After NA-E cleaned the tub NA-E wiped the outside of the tub and the sprayer hose with a MicroKill wipe. Observation of the tub of MicroKill wipes read it had a 1 minute wet set time. The surface did not stay wet for the full 1 minute. It was dry in 10 seconds. NA-E also wiped from the floor to the top of the tub when NA-E cleaned the outside of the tub. NA-E then wiped the cabinets which did not stay wet and the paper towel holder. NA-E then sprayed the shower chair with the Penner disinfectant 2 times but it did not stay wet 10 minutes. There was also a commode tub sitting on the shower chair which was not sprayed at all. NA-E then took their gloves off, took another pair of gloves out of the box, laid them on the sink, did hand hygiene with hand sanitizer and then put the gloves on. This was at 2:17 PM. Review of the undated The System Cleaning for whirlpool tubs revealed the following: press and hold the disinfect button #1 located on the left side of the tube. As the button is held down, the properly mixed cleaning solution is running through and disinfecting the pump and motor. Release the button after you see solution coming out of both jets and you have 1 to 1 1/2 gallons of disinfectant solution in the foot well of the tub. For aqua-air tubs: press and hold the disinfect button #1 located on the left side of the tub. As the button is held down, the properly mixed cleaning solution is running through the air injection system and out all of the air jets. Release the button after you see solution coming out of all the air jets and you have 1 to 1 1/2 gallons of disinfectant solution in the foot well of the tub. Use a long-handled brush to thoroughly scrub all interior surfaces of the tub with the solution that remains in the foot well of the tub. Disinfect the seat by reattaching it to the lift and positioning it over the tub. Use the brush to scrub its surfaces with the remaining solution. Allow for proper disinfectant contact time (Usually 10 minutes or as recommended by the disinfectant manufacturer) and rinse the seat. Replace the seat on the Penner Transfer. Repeat the disinfecting procedure on the wet portions of the lift's upper arm and latching mechanism. Remove the plug from the drain. For Whirlpool tubs, spray water from the shower sprayer into the back outlet until clear water appears from the inlet. Repeat this procedure with the front outlet. Rinse the tub's interior surfaces thoroughly with the shower sprayer. For Aqua-Air tubs spray water from the shower sprayer to rinse out most of the disinfectant solution. Then press and hold the rinse button (32) until you see clear water (not soapy) coming out of the air jets. Release the rinse button. Finish rinsing the interior surfaces of the tub with the shower sprayer. Start the air blower by pushing the Aqua-air button #7. Allow it to run for 30 seconds. This pushes the rinse water out of the air injection system. If this was the last bath of the day, allow the blower to run for 2 minutes to dry out the system. Stop the air blower by again pushing the Aqua-Air button #7. There was a picture of the tub on the document. Observation of the facility tub on 2/26/20 at 4:40 PM with the ICC revealed the tub not have any outlets and had a button for the air jets. The ICC confirmed the tub in the tub room looked similar to the tub on the document indicated as an Aqua air jet tub. Observation of the facility tub on 2/26/20 at 4:43 PM with the DON revealed the DON said it was a Cascade side entry tub and thought it looked like an Aqua air tub as there were not outlets. Review of the untitled facility documents identified by the DON as the bathing records for (MONTH) 2019 through (MONTH) 2020 revealed documentation all of the facility residents received a bath during the timeframe of the outbreak of CP-CRE, (MONTH) 2019 to the present. Review of the Penner Disinfectant Cleaner dated 7/7/2011 revealed the following: To disinfect inanimate, hard, non-porous surfaces add 2 ounces of per gallon of water. Apply solution. Allow to remain wet for 10 minutes. Review of the undated Medline Micro-Kill One Germicidal Wipes revealed the following: Exposure time for Escherichia coli and [DIAGNOSES REDACTED] pneumoniae is 1 minute at room temperature. Requested documentation of the first case of CP-CRE from the DON. On 2/27/20 at 9:17 AM Resident 31 tested positive for CRE on 12/9/2019 when they were hospitalized . Resident 31 returned to the facility on [DATE] and had been in strict contact isolation since then. The DON also provided a list of residents who tested positive for CP-CRE (Carbapenemase Producing Carbapenem-Resistant [MEDICATION NAME]-an antibiotic resistant bacteria) and the dates: Resident 29 on 12/27/2019 [DIAGNOSES REDACTED] pneumoniae; Resident 6 on 12/27/2019 eschericia coli; Resident 14 on 1/9/2020; Resident 1 on 1/29/2020 [DIAGNOSES REDACTED] pneumoniae; Resident 30 on 1/29/2020 [DIAGNOSES REDACTED] pneumoniae; Resident 22 on 2/12/2020 [DIAGNOSES REDACTED] pneumoniae; Resident 28 on 2/12/2020. Interview with the DON on 2/27/20 on 11:07 AM revealed Resident 31 took a shower and had their own shower chair in their room as Resident 31 was CRE positive. Resident 21 took a shower and Resident 21's was the shower chair that was in the bath house that NA-E had sprayed twice and it had not remained wet for the full 10 minutes. The DON revealed that if a resident wanted a shower, the staff just put them in the tub and used the shower attachment. Otherwise all of the other residents received a tub bath. The DON revealed they did not know if the staff were allowed to hold resident clothing and linens up against their uniforms or smocks. The DON revealed the expectation was that the staff were supposed to take linens and fill their cart. If they were going to leave it in the hallway they had to cover it. When they were going into the room they were supposed to grab everything for that resident depending on the resident and they were supposed to take 2-4 towels and washcloths. If they took linen into one room they could take it out of that room and take it into another resident's room. If they took linen into one resident's room and didn't need it had to be laundered and not used for another resident. The DON revealed the staff could not take the linen into another resident's room. The staff were allowed to keep the laundry hampers in the hall during am and pm cares so they were not dragging soiled linens down the hall. The DON confirmed that NA-F should not have entered resident rooms with the linen after they had taken the linen into another resident's room; when NA-F crossed the plane of the resident's room with the linen it should not have been taken into another residents room. That is why the facility had carts. Based on contact precautions, as long as they are not going to touch the residents (at first they were strict but they were running out of PPE) so they looked at the standard of care for contact precautions as long as they weren't going to do any direct resident contact for dropping off meals they did not have to wear a gown. Review of the undated untitled modified contact precautions provided by the DON: Contact isolation-any time you are going to come into contact with the resident or the residents belongings you must wear a (sic) isolation gown. The only time that you do not need to wear isolation gowns is: if you are going into the resident room to deliver laundry, deliver mail, deliver meal tray or just shut off a call light. When you do go in to do any of these things you must: Do hand hygiene: wash your hands or use hand sanitizer. Apply gloves. Make sure that you or your clothing does not touch the resident or the residents belongings. Deliver what you need to or do what you need to do. Remove gloves. Hand hygiene: wash with soap and water or use hand sanitizer. Interview with the DON on 2/27/20 at 12:55 PM revealed they did not have documentation of communication with ICAP/ASAP (state agencies responsible for infection surveillance when outbreaks of communicable diseases occur in facilities) when they modified the contact precautions. The DON revealed the Administrator made the decision to do the modified (no gown) contact precautions based on the contact precautions information they had. The DON pointed out the statement on the contact precautions document: Wear gown when entering room or cubicle and whenever anticipating that clothing will touch patient items or potentially contaminated environmental surfaces. The DON revealed the facility did not have a procedure in place if the staff did not wear a gown, entered a CP-CRE room and got coughed on or inadvertently contaminated their uniform. The DON revealed that the equipment and surfaces needed to be wet for the amount of time per the recommendations for the Penner Disinfectant and the Micro-Kill wipes. The DON confirmed NA-E should have performed hand hygiene before touching the gloves and the wet times were not long enough on the tub, shower chair, sprayer and sprayer hose, and the cabinets. Interview with the DON on 2/27/2020 at 1:37 PM revealed they didn't know how or when the first resident had CP-CRE or how long it could have been spread. The DON confirmed they had residents who initially were negative for CP-CRE and then were positive at a later time while they were residing in the facility. On 2/27/20 at 2:27 PM the ICC provided the list of residents who were initially negative and then had positive CP-CRE tests while they were in the facility: Resident 14 tested negative 12/27/2020 then tested positive 1/9/2020. Resident 1 tested negative 1/15/2020 then tested positive 1/29/20. Resident 30 tested negative on 1/15/2020 then tested positive 1/29/20. Resident 22 tested negative on 1/29/20 then tested positive 2/12/20. Resident 28 tested negative on 1/29/20 then tested positive 2/12/20. There was no documentation any of these residents were out of the facility in the time frames which indicated the residents were in the facility when they contracted the CP-CRE. C. Review of the facility policy Influenza, Prevention and Control of Seasonal dated 8/11/2015 revealed no documentation it had been reviewed annually. Review of the undated facility policy Infection Prevention and Control Policy and Procedures revealed no documentation it had been reviewed annually. Review of the facility policy Antimicrobial Stewardship Program dated 11/16/2017 revealed no documentation it had been reviewed annually. Interview with the DON on 2/27/20 at 2:28 PM confirmed there was no documentation the facility policies had been reviewed annually. D. An observation of the contact isolation precautions for Resident 6 revealed that a sign on gold paper and placed on Resident 6's door stated anyone entering the room must wear a gown and gloves at all times. Also on a pink sign were instruction for putting on PPE (Personal Protective Equipment) which was complete hand hygiene, apply gown, mask, goggles, or face shield and gloves. An observation on 2/24/2020 at 12:46 PM of ES-H (Environmental Services) delivering laundry into the isolation room for Resident 6 revealed that ES-H cleansed hands with hand sanitizer and walked into the room without applying a gown. An interview on 2/24/20 at 1:00 PM with ES-H revealed that the laundry staff because those staff don't come into contact with the residents only have to wear gloves into the room. An interview on 2/24/20 at 1:07 PM with ES-J revealed the type of PPE worn depends on the job you're doing at the time. Laundry staff only have to wear a pair of gloves into the room since there was no contact with the resident. Housekeeping need to wear a gown, gloves and booties into the isolation rooms. ES-J stated the staff have been doing this forever and are frazzled. Working with the Health Department and getting all kinds of instruction was overwhelming. D. Observation on 2/25/20 at 8:21 AM of NA-E who was taking a breakfast meal to Resident 6 revealed that NA-E was wearing only gloves into the room. NA-E after doing unobserved hand hygiene in the restroom because this surveyor could not get on the PPE (Personal Protective Equipment) in time, went into Resident 23's room and informed Resident 23 that the bath for this resident was ready. NA-E did not complete hand hygiene before going into Resident 23's room. NA-E then went around the room touching the closet door and dresser drawers gathering clothing for Resident 23 to put on after the bath. Review of a Sign at nurses' station that states: Midwest Covenant Home- * Contact Isolation-Any time you are going to come into contact with the resident or the residents belongings you must wear a isolation gown. *The only time that you do not need to wear isolation gowns is: 1. If you are going into the resident room to deliver laundry, deliver mail, deliver meal tray or just shut off a call light. When you do go in for these few things you must: a. Do hand hygiene wash your hands or use hand sanitizer b. apply gloves c. Make sure that you or your clothing does not touch the resident or the residents' belongings d. Deliver what you need to or do what you need to do. e. Remove gloves f. Hand hygiene wash with soap and water or use hand sanitizer. There was no documentation or education on the posting or anywhere in the facility to instruct staff what the process was or what to do if the staff not wearing a gown were touched by a resident or the residents personal items came into contact with the staff or the staff 's clothing. Observation on 2/27/20 at 11:39 AM of ES-H (Environmental Services) entering the isolation room for Resident 6 revealed ES-H reached into the pocket of ES-H uniform and removed a pair of gloves and applied them without doing hand hygiene. ES-H then entered the room without putting on an isolation gown. An interview on 2/27/20 at 1:24 PM with the DON (Director of Nursing) revealed the DON did not know what the precautions were if the staff touched items in the room without gloves on or if the resident touched the staff who did not have a gown on. The staff person then would be contaminated and if leaving the room would potentially contaminate everyone the staff person came into contact with. DON stated the staff are being instructed if the staff find out the resident needs something more than just answering the call light. The staff need to remove the gloves. Sanitize the hands and put a gown on then help the resident. Observation on 2/27/20 at 1: 42 PM of the sign outside Resident 22's room a yellow sign on the door that states When entering this room please wear a gown, gloves and mask at all times. Resident 22 had just returned from the hospital around 5:00 PM on 2/26/20 with a [DIAGNOSES REDACTED]. Observation on 2/27/20 at 1:50 PM of RN-K (Registered Nurse) entering the room for Resident 22 revealed RN-K did hand hygiene and applied gloves, gown was applied and a face mask. RN-K then turned off the nebulizer machine (machine used to administer aerosol medication) for Resident 22. Observation on 2/27/20 at 1:57 PM NA-C (Nurse Aide) getting Resident 22 ready to take to the bath revealed NA-C completed hand hygiene with hand sanitizer before applied gloves and a gown before entering the room. NA-C went about the room touching the closet door, the residents' bedside table, and the recliner that the resident was sitting in. Touching the items in the room contaminated the gloves worn by NA-C. NA-C was not wearing a face mask while in the residents' room and NA-C was within 2 feet of Resident 22. Resident 22 stated Resident 22 had to go to the restroom. NA-C got the isolation lift from the hallway by the door to Resident 22's Room and touched the lift without removing the gloves and doing hand hygiene after touching items in the room. This contaminated the handles of the lift. NA-C shut the door to take Resident 22 to the restroom. After 5 minutes NA-C opened the door and placed the contaminated lift in the hallway. NA-C then proceeded to assist Resident 22 out of the room in Resident 22's contaminated wheelchair down the hallway. NA-C was wearing the same gloves that were worn to push the lift into the hallway to push the wheelchair down the hallway. NA-C was pushing the wheelchair and pulling the lift contaminated lift that hadn't been cleaned from the hallway behind them. Resident 22 was brought down the hallway, by other residents, in the contaminated wheelchair that was in residents' room. Wheelchair was not wiped down and resident was not wearing a mask or gown. Resident 22 was wearing the same clothes Resident 22 had been wearing this morning. The door to the bath house was open and NA-C went inside with Resident 22, the contaminated wheelchair and contaminated lift which contaminated the bath house. Review of the undated CRE positive procedure for going to designated activity the process was to: cleaning the resident wheelchair (including wheels and high-touch surfaces like handles), putting on clean clothes; clean resident hands; use reasonable distance from others when positioning the residents'; paper copies of supplies (thrown away after use, i.e. song book); push to activity and push back when done. An interview on 2/27/20 at 2:15 PM with MA-L (Medication Aide) revealed that it is staff preference as to what you want to wear for mask, gown or gloves when entering Resident 22's room. Observation on 2/27/20 at 3:04 PM of Resident 22 sitting at the nurses' station within 3 to 4 feet of the other residents at the activity. Resident 22 was sitting in the same wheelchair that Resident 22 had been taken to the bath house in. Resident 22 was not wearing a mask. When other residents or staff wanted to go down the South hallway they would have to walk within 2 feet of the residents from contact isolation rooms. An interview on 2/27/20 at 3:34 PM with RN-K (Registered Nurse) revealed that Resident 22 was not coughing much at this time and Resident 22 was receiving nebulizer breathing treatments and hopefully would start to cough up some of the secretions from the lungs. Review of the CDC (Centers for Disease Control and Prevention) article Healthcare-associated Infections revealed that the Healthcare Facilities should- Ensure precautions are implemented for CRE (Carbapenem-resistant [MEDICATION NAME] ) colonized or infected patients. These include: *Whenever possible, place patients currently or previously colonized (Some people have germs on or in their body, but those germs do not cause an infection (when germs enter the body, often through medical devices like ventilators, intravenous catheters, urinary catheters, or wounds caused by injury or surgery) or infected with CRE in a private room with a bathroom and dedicate noncritical equipment (e.g., stethoscope, blood pressure cuff) to CRE patients. *Have and enforce a policy for using gown and gloves when caring for patients with CRE. *Have and enforce policies for healthcare personnel hand hygiene before and after contact with patient or their environment, and increase emphasis on hand hygiene on a unit caring for a patient or resident with CRE. *Healthcare personnel should follow standard hand hygiene practices, which include use of alcohol-based hand sanitizer or, if hands are visibly soiled, washing with soap and water. *When a patient with an unusual type of carbapenemase-producing CRE is identified in your facility, work with public health to prevent spread, including following guidance to assess for ongoing transmission. F. Record review of the history and physical documentation by the physician for Resident 31 dated 2/9/20 revealed that the resident had a urine lab test confirming that the resident's urine contained Carbapenem-resistant [MEDICATION NAME] (CRE) [DIAGNOSES REDACTED] (a type of bacteria that has become resistant to carbapenem, a class of antibiotic used to kill bacteria). Observation on 2/25/20 at 2:45 PM revealed that Nursing Assistant C (NA-C) entered the room of Resident 31 without putting on personal protective equipment (PPE) (protective clothing such as gown, gloves, or mask used to protect the wearer's body from infection). Resident 31 was in isolation precautions (requiring the use of gloves, gowns, and hand washing when in the resident room to help stop the spread of germs from one person with a known infection to another) and disposable PPE was available in a holder hanging on the resident's door for staff use. NA-C exited the room of Resident 31 carrying linens and did not perform hand hygiene. NA-C then carried linens into the room of Resident 3. Interview on 2/27/20 at 12:57 PM with the facility Director of Nursing (DON) confirmed that staff are required to wash the hands with soap and water or with alcohol based hand rub when exiting a resident room. |
2020-09-01 |