| 2239 |
ALPINE VILLAGE RETIREMENT CENTER |
285190 |
706 JAMES STREET |
VERDIGRE |
NE |
68783 |
2019-02-26 |
880 |
E |
0 |
1 |
1UP111 |
LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 Based on observations, record review and interview; the facility failed to ensure hand hygiene and/or gloving was provided when indicated during the completion of blood glucose testing for Resident 10 and with administration of an eye drop for Resident 25. This had the potential to put 8 residents (Residents 25, 15, 19, 23, 1, 8, 29 and 12) who received routine eye drops and 5 residents (Residents 10, 32, 29, 12 and 18) who received routine blood glucose testing at increased risk for potential cross contamination. The total sample size was 21 and the facility census was 32. Findings are: [NAME] Review of the facility policy titled Standard Precautions (undated) revealed standard precautions included the following practices: -hand hygiene refers to hand-washing with soap or using an alcohol based hand rub; -hands were to be washed with soap and water whenever visibly soiled with dirt, blood or body fluids, or after direct or indirect contact with such; -wear gloves when anticipated direct contact with blood, body fluids, mucous membranes, non-intact skin and potentially infected material; -change gloves as necessary during the care of a resident to prevent cross contamination from one body site to another; and -remove gloves promptly after use, before touching non-contaminated items and environmental surfaces and before going to another resident and wash hands immediately to avoid transfer of microorganisms. B. During an observation of blood glucose testing on 2/21/19 at 11:30 AM, the following was observed: -Registered Nurse (RN)-D gathered supplies at the medication cart in the corridor, then entered Resident 10's room and set up supplies on a table. Without washing hands, RN-D donned gloves and proceeded to perform blood glucose testing; -RN-D removed disposable gloves and without performing hand hygiene, gathered supplies and returned to the medication cart; -still without completing hand hygiene, RN-D donned a clean pair of gloves and proceeded to cleanse the glucometer (a machine used to determine a resident's blood glucose level); and -RN-D removed gloves and without washing hands or using hand sanitizer proceeded to push the medication cart to the dining room. C. During an observation on 2/25/19 at 9:11 AM, RN-I positioned the medication cart outside of Resident 25's room. Without performing hand hygiene or donning a pair of gloves, RN-I administered an eye drop into both of Resident 25's eyes. D. During an interview with the Director of Nursing on 2/26/19 at 11:45 AM the DON confirmed the following: -staff were to follow the facility policy regarding hand hygiene and the use of disposable gloves; -8 residents (Residents 25, 15, 19, 23, 1, 8, 29 and 12) received routine eye drops; and -5 residents (Residents 10, 32, 29, 12 and 18) had routine blood glucose testing. |
2020-09-01 |