| 276 |
GOLD CREST RETIREMENT CENTER |
285065 |
200 LEVI LANE |
ADAMS |
NE |
68301 |
2019-03-05 |
880 |
F |
0 |
1 |
MX7V11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 174 NAC 12-006.17 Based on observation, record review, and Inteview, the facility failed to ensure that hand hygiene and gloving during resident care procedures were performed in a manner to prevent the potential cross contamination for 3 residents (Residents 1, 5, and 88) out of 3 residents sampled; and failed to store clean linens inches above the floor in the linen storage closets in halls 100 and 300. This had the potential to affect all residents in the facility. the facility failed to ensure that hand hygiene and gloving during resident care procedure's were performed in a manner to prevent the potential cross contamination for residents # 5, 1, and 88. and failed to store clean linens 6 inches above floor in the linen storage closets in hall 100 and 300 this had the potential to affect all residents in the facility. The facility census was 35. Findings are: [NAME] Review of Resident 1's undated Face Sheet revealed Resident 1 was admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 2-13-19 revealed the resident had a stage 2 pressure ulcer (per the MDS manual: Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). ) Interview on 3-4-19 at 2:56 PM with the MDS-C (MDS Coordinator) revealed the resident's pressure ulcer on the heel began on 8-24-18. The resident had been evaluated by the Physician several times at a wound clinic and the wound was healing but very slowly. Observation on 03/04/19 at 10:09 AM revealed RN-E (Registered Nurse) performed wound care to Resident 1's left heel pressure ulcer in the resident's room while the resident was in bed. RN-E had brought wound supplies into the room on a cart from the medication supply room. RN-E entered the resident's room, then washed the top of the cart with a disinfectant wipe. Without first performing hand hygiene, RN-E applied gloves to both hands then proceeded to clean a pair of scissors with a Super Sani Plus disinfectant wipe. Without changing gloves, RN-E used the scissors to remove the rest of the old wound dressing from Resident 1's right leg. RN-E cleansed the wound, then changed gloves without performing hand hygiene. RN-E then handled the new dressing in the gloved hands and applied the dressing directly to the left heel wound followed by the dry dressing and wrap. Review of the undated facility policy 'Handwashing' revealed absence of direction about washing hands related to glove usage. Policy did reveal to wash hand before and after the staff's shift and after each resident. It was absent direction to wash hands before procedures or before contact with residents. Review of the CDC Guidelines revealed Healthcare Providers were to perform hand hygiene after glove removal and after contact with inanimate objects in the immediate vicinity of the patient. B. Observation on 03/04/19 at 12:08 PM revealed RN-E (Registered Nurse) performed a blood glucose check using the Assure Platinum test strips on Resident 88. After the procedure, RN-E wiped the glucometer machine with a Super-Sani Plus wipe for less than 15 seconds and did not perform a wet-set contact time on the machine to disinfect the machine. Inteview on 3-5-19 at 2:59 PM with LPN-J (Licensed Practical Nurse) revealed and demonstrated how to clean a glucose machine. LPN-J wiped the machine with a Super Sani Plus disinfectant wipe then discarded the wipe. LPN-J denied knowledge of the the manufacturer instructions of a wet-set contact time of 3 minutes and denied that was the facility practice to clean items. Review of the manufacturer instructions on the container of the Sani-Cloth Plus disinfectant wipes revealed to disinfect nonfood contact surfaces to use a wipe to remove heavy soil. Obtain a new clean wipe and thoroughly wet the surface to be disinfected, and the surface must remain visibly wet for a full three minutes. If needed use additional wipes to assure a continued 3 minute wet contact time, then let air dry. Review of the undated facility policy titled 'Blood Glucose' revealed to clean the glucose meter with a Super Sani cloth. The policy was absent about the manufacturer instructions of the wet contact time to actually disinfect the surface. C. Record Review of Resident 88's CCP dated 2/21/19 revealed that Resident 88 had a [DEVICE] (GT) ( Surgical creation of an opening in the abdominal wall for the purpose of introducing food into the stomach) in place for nutritional needs. Record review of Resident 88's Treatment Administration Record (TAR) dated (MONTH) 2019 revealed and order to wash Resident 88's [MEDICAL CONDITION] ( trach) ( a surgical incision to the neck, to provide open an airway) site one time per day. Observation on 2/27/19 at 9:30 AM revealed that Resident 88 was seated in a wheelchair in the activity lounge. Resident 88's feeding tube tubing was draped down and touched the wheel of the wheelchair. Observation on 02/28/19 at 1:10 PM revealed that Resident 88 was seated in a wheelchair in the residents room. The tube feeding tubing was dangling and intertwined in wheelchair wheel. Interview on 02/28/19 at 1:30 PM with DON confirmed that Resident 88's tube feeding tubing should not come in contact with the wheelchair wheel as this could be a potential for cross contamination. Observation 03/04/19 between 8:50 AM and 9:00 AM with RN E, during treatment to [MEDICAL CONDITION] and GT site, revealed that RN [NAME] did not perform hand hygiene upon entrance to Resident 88's room. Medication Aide ( MA) H entered Resident 88's room to assist RN [NAME] with residents repositioning. MA H did not perform hand hygiene upon entrance or exit to Resident 88's room. RN [NAME] applied gloves, opened the closet door; removed two trash bags from a box on the shelf. RN [NAME] removed the glove on the left hand and replaced it with a new glove. RN [NAME] did not remove or replace the glove on the right hand. Without reforming hand hygiene or changing glove on right hand, RN [NAME] removed the [MEDICAL CONDITION] and cleaned [MEDICAL CONDITION] with the same gloves on, prepared a q-tip with normal saline, wiped [MEDICAL CONDITION] inside to out with a q-tip. RN [NAME] removed the contaminated gloves. With no hand hygiene preformed, RN [NAME] applied new gloves and proceeded to apply a clean dressing to [MEDICAL CONDITION]. Without changing gloves or performing hand hygiene, RN [NAME] proceed to clean Resident 88's GT site with a wet soapy wash cloth. RN [NAME] removed gloves and applied new gloves. Without hand hygiene in between glove changes, RN [NAME] applied a clean dressing to the GT site. Interview on 03/05/19 at 10:51 AM with the DON confirmed the expectation that staff should perform hand washing or sanitizing ( hand hygiene) before and after patient care. The DON confirmed that gloves should be changed in between different site cares and glove changes. D. On 3/4/19 at 10:30 AM an observation during incontinence cares for resident #5 revealed, NA(Nursing Assistant) A and NA B performed peri care (Perineal care is usually called peri care. It means washing the genitals and anal area), during this care both the NAs changed gloves during the process without washing hands between each glove change. On 3/5/19 at 8:30 AM during dining observation NA B was observed to enter the dining room and put on gloves without washing or sanitizing hands prior to putting on gloves. Record review of facility glove removal policy revealed hands should be washed after removing gloves. Record review of World Health Organizations; Glove use and the need for hand hygiene revealed; When an indication for hand hygiene precedes a contact that also requires glove usage, hand rubbing or hand washing should be performed before donning gloves. When an indication for hand hygiene follows a contact that has required gloves, hand rubbing or hand washing should occur after removing gloves. E. An observation on 03/05/19 at 02:30 PM of the linen storage closet on 300 hall had a shelf that was 3.5 inches off the floor. It was noted that a blanket from the shelf hung off the shelf and touched the floor. An observation on 03/05/19 at 02:31 PM of the linen storage area on 100 hall of a shelf that was 3 inches from the floor. Linens were present on the shelf. An interview on 03/05/19 at 02:31 PM with the Administrator confirmed that the shelf on the 300 hall was 3.5 inches from the floor after it had been measured it with a tape measure, and the 100 hall was 3 inches from the floor after it had been measured by a tape measure. |
2020-09-01 |