| 56 |
HOMESTEAD REHABILITATION CENTER |
285049 |
4735 SOUTH 54TH STREET |
LINCOLN |
NE |
68516 |
2017-05-25 |
441 |
D |
1 |
1 |
18U611 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.17 Based on observation, interview and policy review; the facility failed to ensure the glucometer was sanitized in a manner to prevent cross contamination for five residents( Resident 197, 110, 104 31, and 209) of seven residents who used the glucometer, failed to ensure hand washing and glove changes occurred in order to prevent the potential for spread of infection for two residents (Resident 98 and 194); and failed to ensure the mechanical lift was sanitized between resident use for two residents (Residents 194 and 158) which had to potential to cause cross contamination. The facility census was 131. Findings are: [NAME] Observation on 5/24/2017 at 11:35 AM of Licensed Practical Nurse (LPN) V revealed LPN V remove a glucometer (a portable machine used to test the amount of glucose in one's blood) labeled PRN 2 from the medication cart and laid it down on top of the cart. LPN V then took the glucometer into Resident 209's room and laid it down directly on Resident 209's bedside table. LPN V then picked up the glucometer to test Resident 209's blood and laid it back down onto Resident 209's bedside table. LPN V gathered the rest of the supplies, picked the glucometer back up and went back to the medication cart, laying the glucometer back down on top of the medication cart. LPN V proceeded to remove a Sani-Cloth Bleach Germicidal disposable wipe from an individual size packet and wrap the sani cloth around the glucometer machine from front to back. The cloth was not big enough to stay wrapped around the back of the machine. LPN V then laid the glucometer back on top of the medication cart with the sani cloth wrapped around the top of the machine only. LPN V did not make any attempt to wipe the surfaces of the glucometer before wrapping it with the disposable sani cloth. At 11:45 AM (on 5/24/17) LPN V then took out another glucometer machine labeled PRN 3. LPN V took this machine into Resident 104's room, laid the machine directly onto Resident 104's bedside table, picked up the glucometer and tested Resident 104's blood, again laying the glucometer down directly onto Resident 104's bedside table. LPN V then gathered all supplies, left the room and laid the glucometer on top of the medication cart. LPN V then removed another disposable sani cloth and wrapped it in the same fashion as before, laying the machine back on top of the cart with only the top of the machine in contact with the disinfecting wipe. LPN V again failed to make any effort to wipe down the machine with the cloth before wrapping it. LPN V then removed the sani wipe off of the 1st glucometer used labeled PRN 2 and reported the machine needed to air dry now. LPN V disposed of the wipe never wiping down the machine and never touching the underside of the machine. This was observed at 11:46 AM on the same date. At 11:48 AM (on 5/24/17) LPN V proceeded to remove another glucometer machine from the cart labeled PRN 1 and laid it on top of the medication cart. LPN V gathered the supplies and took the machine labeled PRN 1 into Resident 31's room and laid the glucometer directly on top of Resident 31's bedside table. LPN V then picked up the machine and used it to test Resident 31's blood, gathered the supplies and went back to the medication cart, laying the glucometer back on top of the medication cart. LPN V then removed another sani cloth and wrapped this glucometer in the same fashion and laid it back down directly on top of the medication cart. At 11:51 am (on 5/24/17) LPN V picked up the first glucometer (labeled PRN 2) that was now dry and took it to Resident 197's room, laid it on the bedside table before picking it up again to and used it to test Resident 197's blood. LPN V then laid the glucometer back onto Resident 197's bedside table before taking it back out to set it on top of the medication cart. Interview with LPN V on 5/24/17 at 11:58 AM revealed LPN V would proceed to take off the disposable wipes from the machines and replace the glucometers back into the medication cart in the same manner as before, without wiping down any of the surfaces with the sani cloth. Interview with the Director of Nursing (DON) on 5/24/17 at 1:48 PM revealed the policy was not followed for cleaning the machine. Review of the facility's undated policy for Maintenance of Assure Platinum Blood Glucose Monitoring System revealed, Cleaning and Disinfecting guidelines: Remove wipe from container, wipe all sides and end of machine. Allow machine to sit for 10 minutes after using wipe to totally disinfect the machine before using the machine again. It is critical that the meter be completely dry before testing a resident's glucose level. B. An observation on 5/23/17 at 10:02 AM of staff assisting Resident 194 with toileting needs revealed Nursing Assistant (NA)-H and NA-I applied gloves prior to assisting the resident to remove a soiled brief. Further observation revealed NA-I did not remove soiled gloves prior to having contact with/touching clean items. Interviews on 5/23/17 at 10:15 AM with NA-I revealed the staff member did not remove soiled gloves prior to making contact with items considered clean, during the provision of toileting and incontinence care for Resident 194. A review of a facility policy titled PERSONAL PROTECTIVE EQUIPMENT-GLOVES, revised (MONTH) 2009, revealed gloves were to be worn when touching body fluids and excretions. Gloves should be used for one resident contact and then discarded. C. An observation on 5/24/2017 at 10:29 AM of staff providing cares for Resident 98, revealed: Nursing Assistant (NA)-M washed hands prior to and following the provision of care for 7 seconds each time; NA-N was noted to wash hands for 10 seconds prior to providing needed assist Interviews on 5/24/17 at10:35 AM with NA-M and NA-N revealed the Nursing Assistants were knowledgeable of need for recommended 20 seconds for effective handwashing. Both NA-M and NA-N confirmed they did not wash hands for the recommended 20 seconds. A review of the facility policy titled HANDWASHING/HAND HYGIENE, revised (MONTH) 2008, revealed Appropriate ten (10) to fifteen (15) second handwashing or sanitation via an alcohol based hand rub was to be completed before and after direct contact with residents. The policy did not include the most current CDC (Center for Disease Control) recommendation of 20 seconds for handwashing. D. An observation on 5/23/17 at 10:02 AM of staff providing transfer/toileting assistance for Resident 194 revealed: a sit to stand type lift (a reusable mechanical device used to transfer residents from one surface to another) was obtained from a soiled utility area on Station 3, by Nursing Assistant (NA)-H; the lift was visibly soiled with a dried black colored substance noted to the base/foot rest of the lift, a dry crusty substance and debris were noted to the wheels and locking mechanism of the lifts wheels; and the lift was not cleaned/sanitized prior to entering Resident 194's room. Following the use of the lift to transfer Res 194, NA-H removed the lift from the resident's room and proceeded down the hallway, the lift was intercepted by NA-O who positioned the lift next to the wall. NA-O left the lift momentarily and returned taking the lift into resident room [ROOM NUMBER], without sign of sanitation. An interview on 5/23/17 at 10:20 AM with NA-H confirmed the NA did not sanitize the sit to stand lift prior to, or after use with Resident 194. An interview on 5/23/17 at 10:28 AM with NA-O revealed the NA did not sanitized the lift prior to using the equipment to transfer Resident 158, in room [ROOM NUMBER]. A review of the facility policy titled CLEANING AND DISINFECTION OF RESIDENT CARE ITEMS AND EQUIPMENT dated/revised (MONTH) 2014 revealed reusable Resident care equipment would be cleaned and disinfected according to current CDC recommendations for disinfection between resident use. |
2020-09-01 |