| 18 |
RYDER MEMORIAL HOSPITAL INC |
405018 |
355 AVE FONT MARTELO |
HUMACAO |
PR |
792 |
2017-05-04 |
441 |
F |
0 |
1 |
ZOYB11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a recertification extended survey, observational tour, interviews with the Infection Control Preventionist (employee # 7), Housekeeping Supervisor (employee #9), Infection Control Coordinator (Hospital/employee #10), Infection Control Committee President (employee # 11), policies & procedures (P&P's) review performed on 5/3/17 at 10:00 am it was determined that the facility failed to established an accurate mechanism for preventing, investigating and reporting infection control issues. Findings include: 1. During observational tour performed on 5/3/17 at 10:00 am it was found in the janitor's room the following items: - 2 gallons of Sodium Hypoclorite (known as Clorox) - 2 gallons of Lemon Quat Germicidal detergent - 1 gallon of Green Apple cleaner for floor and surfaces These 5 products were not labeled when they were opened for their use. According to interview with the Housekeeping Supervisor (employee # 9) performed on 5/3/17 at 2:00 pm, he stated the following: All opened cleansing containers must be labeled with date and signed with the initials of the person who opened it. That is part of the policies and procedures of our company. I will check it out because all janitors of our company are instructed about the labeling of the containers. 2. Besides one shelve, it was observed wood and metal sticks unidentified. A red mop was put in a holding rack but it was unidentified. According to interview with the Housekeeping Supervisor, (employee #9) performed on 5/3/17 at 10:00 am, he stated the following: The red mop is used for hazard materials, such as blood, vomits. The green mop is used inside the resident's rooms and the blue mop is used in halls. These mops were not identified, specifically the one that is used for hazards. On 5/4/17 at 10:00 am an observational tour was performed to the janitor room. However, no improvement was observed in this room. The germicidal and cleaning containers were not labeled and the wood and metal sticks remained in that room, unidentified. The housekeeping services failed to establish a secure mechanism of labeling and identifying the opened containers and the uses of the cleansing equipment (sticks). 3. During review of the policy and procedure (P&P) for cleansing and disinfection of medical durable equipment performed on 5/3/17 at 3:00 pm, it was found that durable medical equipment will be clean and disinfected with germicidal solution that has been approved by the facility. The P&P's step 2 procedure mentions the following quote: the sphygmomanometer cuff will be disinfected as many times as needed during the round of blood pressure measurements. However, this step does not specify if the blood pressure cuff will be disinfected after its use between residents. Saying to be disinfected as many times as needed could be interpreted differently by the nursing staff. For example: during morning observational tour by resident's rooms performed on different days and hours, it was observed that the Licensed Practical Nurse (LPN) was performing the blood pressure measurement procedure. She put the paper towel around resident's arm, put the sphygmomanometer and when finished the procedure, she took out the equipment, put the cuff in the equipment basket and finished her intervention with the resident. She went out of the room and continued her duties. The LPN failed to clean and disinfect the sphygmomanometer cuff. During interview with the Infection Control Preventionist (employee #7) performed on 5/3/17 at 2:00 pm she stated the following: The nursing staff puts a piece of paper towel around resident's arm. They performed the procedure of measuring the blood pressure and then they clean with alcohol swabs the equipment, including the thermometer. However, the P&P for cleansing and disinfection of medical and durable equipment does not mention which equipment will be disinfected with alcohol swaps and what other durable equipment will be disinfected with other approved germicidal by the Infection Control Program of the facility. The facility failed to review with actualized professional guidelines the P&P's for cleaning and disinfection of the medical durable equipment in a manner that the nursing staff can follow the cleansing and disinfection procedures. 4. During interview with the Infection Control Preventionist (employee #7) related to the hand washing competencies evaluation for the rehabilitation program staff, she stated the following: The Physical Therapy (PT) Supervisor is in charge of performing the competencies on their staff. If during her observations she watches deficient practices, she works directly with her staff members. I don't receive information of when she performs the evaluation and I do not know if there is a plan of corrective actions for the staff members. The PT Supervisor discusses the infection control issues of her program on the Infection Control staff meetings that are performed quarterly. The PT Supervisor does not share with me information related to deficient practices performed by her staff. She writes her quality indicators and reports and send them to the Medical Director of the Rehabilitation Services and to the Infection Control Coordinator (hospital and SNF coordinator). The facility failed to develop a collaborative plan where the PT Supervisor shares with the Infection Control Preventionist (employee #7) information related to deficient practices on infection control procedures that were performed by the physical, occupational and speech therapists staff, in a manner that both professionals can develop an ongoing surveillance plan with specific indicators and with monitoring and tracking activities as part of the quality of care to be observed. 5. During review of P&P's related to the [DIAGNOSES REDACTED] (TB) screening procedures, performed on 5/3/17 at 10:00 AM, it was found that the facility failed to develop a mechanism where a TB screening will be performed to all residents during the admission process. According to the review of the nursing initial assessment, physician's history and physical exam form and other documentation forms, it was found that the professional staff is not performing a TB screening to each resident. 6. Quality reports of the facility's Infection Control program were reviewed on 5/4/17 at 9:25 am accompanied by the Infection Control Preventionist (employee #7) and the hospital Infection Control Coordinator (employee # 10). It was not found on these reports analysis discussion of the antibiograms. According to interview with the hospital and SNF Infection Control Coordinator (employee # 10), she stated the following: The Infection Control Committee discussed on quarterly meetings the antibiotics analysis. Right now, we don't have the person who was responsible of obtaining the data of the antibiotics and put that data on a graphic chart presentation. There is a new person that was performing that function but the physician that leads this committee was not satisfied with the graphic chart presentation. He decided to postpone the antiobiogram presentation until the graphic chart was performed better. Since (MONTH) (YEAR) until (MONTH) (YEAR), we have not discussed the antibiogram. During interview with the Infection Control Committee President (employee # 11) performed on 5/4/17 at 11:40 am, he stated the following: The person who prepares the graphic chart with the antibiotic data does not work with us. The person that is working with that data does not know how to prepare a graphic chart. I explained to her how to do it before each meeting. I meet with[NAME](Employee #10) and we discuss all skilled nursing residents that are in antibiotic treatment. However, no evidence of an alternate plan for antibiogram discussion was presented. 7. During QAPI reports review performed on 5/4/17 at 10:00 am accompanied by the Infection Control Preventionist (employee # 7) it was found that the infection control indicators are included on the QAPI program report. According to interview to employee #7, performed on 5/4/17 at 10:00 am, she stated the following: I collect data for each quality indicator. Quarterly, I send the report to the Infection Control Coordinator (employee #10). Every week, on an administrative staff meeting, we discuss the results of the surveillance. We discuss all the indicators that we have identified including those related to the Infection Control Program. I include on the quarterly QAPI reports the infection control indicators. I don't prepare a separate QAPI report of the Infection Control Program. The facility failed to recognize the Infection Control Program as a hospital based institutional program that has to be organized independently with its own surveillance activities and respond to the Administration and Governing Body of the hospital. The facility failed to organize an ongoing infection control surveillance program where all services that provide care to the skilled nursing facility residents participate and collaborate on the development of indicators that are related to infection control deficient practices. There is no integration of the services, such as: Therapy Services, Housekeeping, Dietitian, Social Services and Physician services on the Infection Control Program surveillance activities. |
2020-09-01 |