| 8247 |
THE METHODIST OAKS |
425131 |
151 LOVELY DRIVE |
ORANGEBURG |
SC |
29115 |
2012-02-29 |
441 |
E |
0 |
1 |
5WM211 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on observations, interviews and record review, the facility failed to implement all components of the infection control program. The facility failed to have a process to comply with State Laws and Regulations for reporting communicable diseases and outbreaks and failed to monitor that staff observed transmission based precautions. The facility also failed to ensure that expired instant hand sanitizers were not being stored in 2 of 3 medication rooms and were not being used during patient care on 3 of 6 medication carts. The findings included: Review of the facility's Policy and Procedure Manual revealed no list of Reportable Conditions or communicable diseases to be reported in accordance with State Laws and Regulations. During an interview on [DATE] at approximately 11:30 AM, the Infection Control Nurse stated she didn't know where the list might be. She stated she hadn't seen one and did not know what conditions or communicable diseases were reportable. Review of the infection surveillance logs indicated the facility had 4 ESBL (Extended-Spectrum Beta-Lactamase) infections in the month of January, 2012. The Infection Preventionist was not able to state whether that would constitute an outbreak of a communicable disease and stated she would have to research it. On [DATE] during initial tour, Resident #11 was noted to be on transmission-based precautions. Licensed Practical Nurse (LPN) #3 stated the resident was on contact isolation. Record Review on [DATE] at approximately 10:30 AM revealed the resident had a Culture and Sensitivity on [DATE] which was positive for [DIAGNOSES REDACTED] Pneumoniae ESBL and antibiotic therapy and isolation precautions were ordered on [DATE] when the results were received. At 6:15 PM on [DATE], Certified Nursing Assistant (CNA) #2 was observed delivering the evening meal in the resident's room without donning any PPE (Personal Protective Equipment) prior to entering. Observation of the isolation supplies hanging outside the resident's room at that time revealed an unopened package of isolation gowns containing 5 gowns. On [DATE] at 9:30 AM, observation of the isolation supplies outside the resident's room again revealed an unopened package of isolation gowns. At 10:28 AM, CNA #2 was observed entering the room of Resident #11 without donning any PPE. At 12:38 PM on [DATE], Licensed Practical Nurse #3 was observed sitting in Resident #11's room during a nebulizer treatment without a gown. LPN #3 was observed to be wearing gloves. At 12:52 PM, this surveyor opened the package of isolation gowns and donned a gown to conduct an individual interview with the resident. During the Resident Interview, when asked if the staff wore gowns when they came in to provide care, Resident #11 said Some do. At approximately 9:30 AM on [DATE], a package containing 4 isolation gowns was observed outside the resident's room. At 3:40 PM, the same package was observed outside the resident's room and it still contained 4 gowns. Review of the facility's Transmission-Based Precautions - Categories Policy Statement in the section titled Contact Precautions stated a. Examples of infections requiring Contact Precautions include, but are not limited to: (1) . urinary . infections or colonization with multi-drug resistant organisms (e.g.(for example), .ESBL). In the subsection titled c. Gloves and Handwashing, the policy stated (1) .wear gloves (clean, non-sterile) when entering the room. The subsection titled d. Gown stated (1) . wear a gown (clean, non-sterile) when entering the room if you anticipate that your clothing will have substantial contact with an actively infected resident, with environmental surfaces, items in the resident's room . At approximately 11:52 AM on [DATE], during an interview, the Director of Nursing (DON) stated that the facility provided education and in-services on transmission based precautions. She also stated that the facility monitored staff by identifying new cases of an infection in any given staff members case-load but no monitoring of staff practices was done to ensure that staff observe transmission based precautions to prevent infections from occurring. In addition, the DON stated there was no defending observations of staff not observing precautions. On [DATE] at approximately 10:30 AM, inspection of the Piedmont (A Wing) medication room revealed the following: -One unopened 8 ounce bottle of CliniShield Instant Hand Sanitizer ([MEDICATION NAME] 62% (percent), Lot 01, expiration ,[DATE] was found atop a white, plastic storage unit. On [DATE] at approximately 11:30 AM inspection of the Piedmont (A wing) medication carts revealed the following: -Cart 1: One opened 8 ounce bottle of CliniShield Instant Hand Sanitizer ([MEDICATION NAME] 62%), Lot 01. expiration ,[DATE]. -Cart 2: One opened 8 ounce bottle of CliniShield Instant Hand Sanitizer ([MEDICATION NAME] 62%), Lot 01, expiration ,[DATE]. These findings (medication room and medication carts) were verified by LPN (Licensed Practical Nurse) # 1 on [DATE] at approximately 11:35 AM. LPN # 1 stated that Instant Hand Sanitizer was used to sanitize hands during patient care. On [DATE] at approximately 10:45 AM, inspection of the Riverside (D Wing) medication room revealed the following: -Two unopened 8 ounce bottles of CliniShield Instant Hand Sanitizer ([MEDICATION NAME] 62%), Lot 01, expiration ,[DATE]. -One unopened 8 ounce bottle of Clinishield Instant Hand Sanitizer ([MEDICATION NAME] 62%), Lot 01, expiration ,[DATE] These three bottles were stored on the 2nd shelf, right side of a gray metal storage unit. On [DATE] at approximately 10:55 AM inspection of the Riverside (D Wing) medication carts revealed the following: Cart 1: One opened 8 ounce bottle of CliniShield Instant Hand Sanitizer ([MEDICATION NAME] 62%), Lot 01, expiration ,[DATE]. These findings (medication room and medication cart) were verified by LPN # 2 on [DATE] at approximately 11:45 AM. LPN # 2 stated that Instant Hand Sanitizer was used to sanitize hands during patient care. |
2016-06-01 |