cms_PR: 420
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 420 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2014-05-29 | 441 | F | 0 | 1 | 1FFV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations made with the Infection Control Coordinator (employee #2), during the initial tour with a staff nurse (employee #6), drug pass, review of policies and procedures and review of drug cabinets it was determined that the facility failed to provide a safe environment through an organized infection control program to ensure that staff follows infection control practices, consistently and effectively that complies with professional standards of practice, recommendations of the CDC to promote sanitary and safe care so as to prevent in a manner or reduce the risk of spread of infections as evidenced by nursing staff improperly using 0.9 % Sodium Chloride for irrigation, expired medical supplies in the crash cart, provide housekeeping personnel with policies and procedures for guidance for cleaning and disinfecting the facility, have a organized infection control program, which could affect 17 out of 17 admitted residents (sample selection residents #1 through #8 and random sample residents #1 through # 9). Findings include: 1. During observations of the drug storage room on [DATE] from 10:15 am till 11:00 am accompanied by a Registered Nurse (RN) (employee #6), it was identified that the nursing staff has a tray which contain the supply for residents ' cannulation. In that tray, three bags of 0.9 % Sodium Chloride of 50 milliliter were observed which were not label and one appears to be punch by needle at the hub. The surveyors ask the nurse what were the Sodium Chloride bags use for and the nurse stated they are used for irrigation. 2. The 0.9 % Sodium Chloride that appears to be punch by needle was not label, dated, of when it was used, and as observed it had three needle punches at the hub. As recommended by the CDC, 0.9% Sodium Chloride should not be use for irrigation, and if used it should be for only one patient and discarded immediate. 3. The facility failed to follow proper infection control standards of practice and to avoid cross contamination to residents. 7. Policies and procedures manual were reviewed on [DATE] at 10:00 am, after the revision and based on information provided by housekeeping personnel (employee #4) some deficient practices were identified. Based on this review it was identified that a mechanism to ensure that infection control policies implemented at the facility are based on nationally recognized guidelines and applicable state and federal law are not promoted followed accordingly with the following findings: 8. This facility had an agreement with a private contractor company ( proclean-system Inc) who provide housekeeping services. This company as part of the agreement prepares policies and procedures to guide housekeeping services. However facility did not provide evidence that the company has developed those policies based on nationally recognized guidelines and applicable state and federal law because the reference used to prepare the policies was not included as part of the policies and procedures manual. 9. A mechanism to ensure that proper procedures for effective uses of mops and cloths were followed are not promoted followed accordingly with the following findings: a. Policies included in the housekeeping services manual indicate that mops heads, cloths and dusters are change every two weeks, but did not include provisions for change when used to clean up large spills of blood or other body substances as required by the cleaning and disinfecting strategies for environmental surfaces of the center for disease control 2008 and the Guidelines for Environmental Infection Control in Health Care Facilities (2003). 10. A mechanism to ensure that proper procedures for effective uses of brush used to clean toilets and shower areas were followed are not promoted followed accordingly with the following findings: a. Housekeeping personnel (employee #4) stated on interview on [DATE] at 10:30 am that he had only one brush that he used to clean all the toilets located on resident rooms. He also stated that he use the same brush to clean common shower area tiles and floors. This practice could promote that germs spread form one area to the other. The brush used to clean toilets should not be used to clean common shower area were residents take their bath and perform their grooming tasks. 11. A mechanism to ensure that proper procedures are followed to storage cleaning items as scour pads , towels and mops heads to be used in the kitchen were followed are not promoted followed accordingly with the following findings identified with the kitchen supervisor (employee #8) on [DATE] at 11:50 am: a. Two boxes of scotch brite heavy duty scour, one box of kimtex heavy duty towels and one soft head mop were observed storage in a bathroom located behind the dry storage room in the kitchen. Kitchen supervisor (employee #8) stated on interview on [DATE] at 11:55 am that kitchen personnel use this bathroom on daily basis. Facility failed to comply with Chapter 4 Food code 2013 requirement (,[DATE].11 Equipment, Clothes Washers and Dryers, and Storage Cabinets, Contamination Prevention) who establish that these clean items could not be storage in toilet rooms. 12. The Infection Control Program has a coordinator (employee #2) who is in charge to investigate and establish interventions for preventing and controlling infections. She is part of the nursing staff that provides direct care to residents but performs the infection control duties 8 hours weekly. However, no evidence was found of the Medical Director working with employee #2 for the program development and oversights that include: establishing goals and priorities of the program, planning and implementing strategies to achieve the goals, monitoring the implementation of the program and responding to errors, problems or other identified issues. 13. The Infection Control Committee performed meetings on [DATE], [DATE] and [DATE] of 2013 and on [DATE] of 2014. However, the Medical Director participated only on the meeting performed in [DATE]. No Infection Control meetings were performed after [DATE]. The Medical Director nor employee #2 develops a meeting calendar for [AGE] year. a. The meeting minutes show some issues related to infection control. The infection control topics are general, not specific for the identified issues. a.i. Employee #2 has been obtaining samples from different surfaces such as: walls, floors, drainage on the Physical Therapy area, nurse's station counters, door knobs, patient's refrigerator, medications refrigerator and walkers. During interview with employee #2 performed on [DATE] at 11:00 a.m. she stated: I did obtain those samples for cultures. The Medical Director ordered to do it but he didn't tell the reason for doing it. a.ii. As requested by the surveyor, the results for patient's refrigerator culture were of 6 col/plate Gram Negative Bacilli and 3 col/plate Gram Positive Cocci, medications refrigerator were 4 col/plate Gram Positive Cocci and 18 col/plate Gram Negative Bacilli, a random sample from a resident's door knob the culture results were 5 col/plate Gram Negative Bacilli, a random sample from a walker the culture results were 5 col/plate Gram Positive Cocci and 8 col/plate Gram positive Bacilli, Nursing surface counter culture results were of 12 col/plate Gram Positive Cocci. Those results were obtained on [DATE] thru 13 of 2013. Since these dates, employee #2 did not develop a plan for cleaning and disinfection. No evidence was found of the discussion between the Medical Director with employee #2 related to these issues. According to employee #2, no residents had health issues in a manner that the Medical Director requested to do surfaces cultures in a quarterly period. The Medical Director did not follow the recommendations established by the CDC for obtaining samples for cultures. b. Other areas such as Physical Therapy performed cultures to their [MEDICATION NAME] equipment but no evidence was found of the reasons for performing that duty. No evidence was found of cross contamination between the [MEDICATION NAME] and residents that uses the equipment nor other issues that suggested obtaining a sample for culture. 13. The meeting minutes reveals, they are evaluating the infection control indicators but they do not mention specific identified issues. 14. The meeting minutes reveals that employee #2 did not visit yet the kitchen to do her surveillance but no indicators were found to determine the issues viewed in this area. 15. There were issues mentioned on the meetings such as: mosquitoes problems, physicians are not using gloves when perform ulcer or wound examinations to the residents, nursing staff are not obtaining correctly urine samples, rebottling liquid soap (which is not recommended due to cross contamination) but no evidence was found of a plan of correction develop by employee #2 nor recommendations for the surveillance made by the Medical Director. 16. There is no manual of policies and procedures related to the Infection Control Program. 17. Employee #2 offer incidental education to staff that has infection control issues but there is no a scheduled formal training program. 18. The Quality Coordinator (employee #1) is responsible of obtaining data related to residents that participate on the immunization program. However, this coordinator does not share the data with employee #2. The data that employee # 1 obtains is, how many residents have the Influenza and Pneumococcal vaccines and how many signed the consent avoiding the vaccines. Employee # is not identifying how many residents that did not receive the vaccines, wants to participate in the immunization program so employee #2 can make the arrangements to obtain both vaccines. 19. There is no evidence of the [DIAGNOSES REDACTED] screening on admission or how they will manage an active new case. 20. There is no evidence of the management of food safety, employee health and hygiene policies and procedures, pest control, investigating potential food-borne illnesses and waste disposal. 21. No evidence was found of what employees were designed by the Board of Directors to substitute the Medical Director and the Infection Control Coordinator (employee #2) in case of absent due to sickness, vacations, etc. 22. No policies and procedures were found related of how the Infection Control Program will communicate their findings to the facility's staff and management and how they will implement effective interventions to correct the errors. 23. No evidence was found of the involvement of the interdisciplinary group in the Infection Control Program. 24. No evidence was found of how the facility will report communicable diseases to the State Agency. 25. No evidence was found of the antibiotic review to monitor the appropriate use of it. The physicians order antibiotics to the residents without obtaining cultures (if there is bacteriuria or other signs and symptoms that are suspicious to a possible infection process) and are not evaluating the bacteria resistance vs susceptibility to an specific antibiotic, (cross reference TAG F 281). 4. During observations of the drug storage room on [DATE] from 10:15 am till 11:00 am accompanied by a Registered Nurse (RN) (employee #6), it was identified that the nursing staff has in the back of the nurses ' station multiples drawers which contains the supplies for residents ' cannulation (IV Catheter, Alcohol and port access infusion set). 5. The drawers on the drug store room contain two port access infusion set expired on [DATE], seventeen IV catheters 20x1 expired on the ,[DATE], six IV catheter 22x1expired on ,[DATE] and one [MEDICATION NAME] alcohol expired on [DATE]. 6. The facility failed to follow proper infection control practice and standards of practice to avoid cross contamination to residents. | 2017-06-01 |