cms_SC: 8300
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8300 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2012-05-02 | 441 | L | 0 | 1 | YK4D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Extended, and Complaint Surveys, based on record reviews, observations, interviews, and review of facility infection control policies and procedures and tracking documents, the facility failed to implement treatment and contact precautions in a timely manner, and/or failed to ensure contact precautions were maintained, and/or failed to ensure accurate monitoring and tracking of infections for 7 of 9 residents reviewed who had positive test results for Clostridium Difficile (C-Diff), (Residents #1, #4, #5, #6, #8, #10, and #12). The physician was not notified of the onset of gastrointestinal signs and symptoms of Clostridium Difficile (C-Diff) in a timely manner for four of nine sampled residents reviewed with[DIAGNOSES REDACTED] (Residents #1, #4, #8, #12). Three of these four developed symptoms after admission to the facility (Residents #1, #4, #12). This failure to notify the physician in a timely manner resulted in significant delays in treatment and increased risk/potential for transmission of infection. The facility failed to ensure contact precautions were maintained appropriately for Residents #1, #4, #5, #6, #8, #10. Infection surveillance data was inaccurate/missing for residents who had positive test results for[DIAGNOSES REDACTED] (Residents #1, #4, #6, #8, #10, and #12). The Infection Preventionist (IP) was not knowledgeable of job duties and responsibilities for the infection control program. The facility failed to ensure that surveillance data was reviewed frequently enough to identify, investigate, and address the causes of any trends. Facility staff failed to identify an outbreak of[DIAGNOSES REDACTED] and notify the local office of the Department of Health and Environmental Control. Procedures were not in place and/or followed to ensure that facility laundry was hygienically cleaned. Procedures were not in place and/or followed to ensure appropriate daily and terminal cleaning of isolation rooms, including those rooms of residents on contact precautions for[DIAGNOSES REDACTED]. The findings included: The facility admitted Resident #1 on 8/26/11 following hospitalization for Altered Mental Status. She was discharged with [DIAGNOSES REDACTED]. The hospital discharge summary noted that she had been treated with [MEDICATION NAME], which had been changed to [MEDICATION NAME] to continue at the nursing facility until 9-2-11. Record review and interviews revealed that the facility twice failed to identify signs and symptoms of[DIAGNOSES REDACTED] and notify the physician in a timely manner so that interventions could be implemented to treat the infection and prevent its' transmission. Review of Physician Telephone Orders with the Assistant Director of Nurses (ADON) on 5-1-12 at 10:20 AM revealed that on 8-27-11, the physician ordered intravenous fluids for dehydration. On 8-29-11, the resident was started on [MEDICATION NAME] IM (intramuscular) for 3 days for signs and symptoms of a UTI. Review of the Daily Skilled Nurse's Notes with the ADON revealed that on 9/8/11, the resident had a watery, foul smelling stool. The physician was notified and ordered a stool specimen to check for[DIAGNOSES REDACTED]. On 9/9/11, the facility was notified of a positive result and the physician ordered treatment with [MEDICATION NAME] for 10 days and isolation precautions. [MEDICATION NAME] was completed on 9-19-11. Review of the computerized Activities of Daily Living (ADL) Records on 5-1-12 at 11 AM with Certified Nursing Assistant (CNA) #1 and the ADON revealed that the resident began having 1 to 2 loose stools daily (when bowel movements were documented) on 8-28-11, at times having an odor. Multiple entries had no consistency noted. There was no evidence that the physician was notified until 9-8-11 when the nurse in the Daily Skilled Nurse ' s Notes made the first notation. Following completion of the [MEDICATION NAME] on 9-19-11, review of the Daily Skilled Nurse's Notes and the computerized bowel movement (BM) records revealed that the resident had no further symptoms until 9-24-11 when she experienced four diarrhea stools per the CNA documentation and diarrhea off + on by the nurse. The Physician/Extender saw the resident on that date, but the Progress Note indicated that the resident was seen for altered mental status .preceded by weakness and dark urine. There was no mention of current diarrhea/loose stools and no immediate interventions. The document erroneously listed [MEDICATION NAME] as an active medication starting 9-19-11. There was no evidence that the physician was notified of the recurrence of diarrhea until two days later when a 9-26-11 Physician's Telephone Order was written to Recheck stool for[DIAGNOSES REDACTED]. The 9-26-11 Progress Note again listed [MEDICATION NAME] as an active medication starting 9-19-11. On 9-28-11, the[DIAGNOSES REDACTED] toxin was reported as positive and the physician ordered treatment with [MEDICATION NAME] for ten days. Record review and interviews also revealed that contact precautions were not appropriately maintained for Resident #1. Review of the Daily Skilled Nurse's Notes revealed an entry on 9/6/11 describing the resident as pacing in the hallway and rambling, wandering into other resident's rooms. Further review revealed the resident was not confined to her room once she was placed on contact precautions. On 9/10/11, she ambulated in the hallway and entered other resident's rooms. According to nurses' notes, the resident was often brought out to the nurses' station in a recliner chair on the following days: 9/12, 9/13, 9/14, 9/16, and 9/21/11. The nurse's note on 9/21/11 said the resident was ambulated by staff for toileting and needed two people for assistance most of the time. A nurse's note on 9/22/11 stated the resident was in a rocking chair in the lobby. Staff continued to bring the resident out of her room to sit by the nurses' station, as noted on 9/25/11. Documentation in the nurses' notes continued to show that the resident was brought out to the nurses' station (10/5, 10/9, and 10/11) even though she tested positive for[DIAGNOSES REDACTED] again on 9/28/11. Nurses' notes from this period also showed the resident placed her hands in her brief and then spread fecal matter. A nurse's note on 10/9/11 said the resident was in her chair at the nurses' station disrobing, and digging in her brief. On 10/13/11 the resident attempted to put her soiled fingers in her mouth. When the nurse redirected the resident, the resident attempted to place her hands all over the writer's belly & arm. The nurse's note did not say if a gown and gloves were implemented at the time of this interaction. A nurse's note on 10/15/11 said she frequently placed her hands in her brief and then on her face. Review of the medical record failed to show an assessment by staff to show why the decision was made to allow the resident into the common areas of the facility, and how the other residents would be kept safe from possible contact with the resident or the environments she visited while positive for[DIAGNOSES REDACTED]. During an interview on 5-1-12 beginning at 10:15 AM, the ADON reviewed the medical record and confirmed the above information. She stated that precautions were implemented when the physician gave the order. She further stated that the physician should have been notified and precautions implemented at the onset of symptoms. She was unable to explain why this had not been done. When asked who would assess to determine the extent of contact isolation required, the ADON stated that she did not know. On 5-1-12 at 11:30 AM, the Administrator joined the interview and stated that the Director of Nurses and/or physician would determine if the resident could come out of their room, based on the type of infection and if on antibiotics. When asked how other residents were kept safe from personal contact with Resident #1 when she was out of her room, the ADON stated she did not know. She reviewed the Minimum Data Set for this period and stated that the resident had severe dementia and exhibited inappropriate social behavior. The Administrator stated that the staff routinely kept the resident at the nurses' station from about 10 AM until mid-afternoon daily. He stated there was always someone at the nurse's station, but he can't think how someone could stop resident contact in the immediate area. During the survey, four current residents were noted as cognitively impaired self-mobile. Record review and interview revealed that the infection surveillance information was missing and/or incorrect, thus rendering the data collection incomplete for determining trends and patterns. Review of the facility's Infection Control Log for September 2011 did not show Resident #1 as having[DIAGNOSES REDACTED]. The October 2011 log did show the resident as having[DIAGNOSES REDACTED], but with an incorrect onset date of 10/4/11. During an interview on 5-1-12 at approximately 10:30 AM, the ADON reviewed the 9-11 Infection Control Log with the surveyor and verified that Resident #1's information had not been entered. It was also noted that the entries on the log were by resident name, not by infection onset date, thus making it difficult to determine patterns/trends in a timely manner. She stated that she was responsible for the Infection Control Program and was made aware of infections by review of copies of physician's orders [REDACTED]. When asked why the entries in the log were not in sequence, the ADON stated, I got a pile of telephone orders and I enter them when I get a free moment. When asked if she had identified any patterns/trends, she stated she had not but that she had just been promoted to ADON and made responsible for Infection Control a couple of months previously. She stated she had received no formal training except for how to enter the information into the computer. It was just read the policies and learn as you go. She could not remember signing anything that stated her responsibilities to the infection control program. Review of the ADON's personnel file on 5-1-12 revealed no job description related to her current position or evidence of infection control training. A job description (signed 1-6-12) presented on 5-2-12 noted one of the Areas of Responsibility under Regulatory Compliance included: 7. Assure that the facility, through established systems is in compliance with infection control regulations. Be responsible for reporting to the DON and Administrator all the pertinent information for Quality Assurance in Infection Control. Resident #4 with [DIAGNOSES REDACTED]. Review of the hospital Discharge Summary with the ADON on 5-1-12 at 6 PM revealed that the resident had been treated for [REDACTED]. She was discharged to the facility with a [MEDICATION NAME] treatment to the lower leg. Record review and interviews revealed that the facility failed to identify signs and symptoms of[DIAGNOSES REDACTED] and notify the physician in a timely manner so that interventions could be implemented to treat the infection and prevent its' transmission. Review of the Daily Skilled Nurse's Notes revealed that on 12/19/11, the resident experienced a large amount of diarrhea stool with mucous. The physician was notified on 12-19-11 and an order received for Stool for[DIAGNOSES REDACTED] ASAP (as soon as possible). Dx (Diagnosis) possible[DIAGNOSES REDACTED]. A laboratory report dated 12/22/11 showed the resident tested positive for[DIAGNOSES REDACTED]. Five days later, on 12/27/11, the physician/extender saw the resident, ordered [MEDICATION NAME] starting on 12-28-11 to treat the[DIAGNOSES REDACTED], and ordered contact isolation. The physician gave an interim Telephone Order on 12-23-11 for Preparation H .apply TID (three times daily) to rectal region, indicating that the resident was suffering from swollen, irritated hemorrhoids. On 12-25-11, the physician/extender wrote to decrease [MEDICATION NAME] from twice daily to be given an as needed basis. Review of the computerized ADL Records on 5-1-12 at 6:40 PM with Certified Nursing Assistant (CNA) #1 and the ADON revealed that the resident began having loose stools on 12-16-11. Again, multiple entries had no consistency noted. There was no evidence that the physician was notified until 12-19-11 when the nurse in the Daily Skilled Nurse ' s Notes made the first notation. Based on review of the facility's Census List, the resident was given a roommate on 12/20/11, after exhibiting gastrointestinal symptoms for three days. However, the census for 12/21/11 did not show a roommate. A laboratory report dated 12/22/11 showed the resident tested positive for[DIAGNOSES REDACTED]. On 12/26/11, the facility put another roommate in with the resident. The physician ordered contact isolation, and [MEDICATION NAME] to treat the[DIAGNOSES REDACTED] on 12/27/11. A nurse's note on 12/28/11 revealed the resident was transferred from room [ROOM NUMBER] to room [ROOM NUMBER] due to the ordered contact precautions. The resident's new roommate remained in room [ROOM NUMBER], a likely more contaminated environment. Review of the medical record failed to show any reason for the delay in testing the resident's stool sample (12/19 to 12/22/11). There was also no rationale to show why there was a delay in ordering treatment and the contact precautions (12/22 to 12/27/11). There was no information concerning the delay in isolating the resident from other residents (12/16 to 12/28/11), and/or why it was more appropriate to move the resident infected with[DIAGNOSES REDACTED] to a clean room while leaving the roommate without infection in the more compromised environment. During an interview on 5-1-12 beginning at 6 PM, the ADON reviewed the medical record and confirmed the above information. She stated that the physician should have been notified and precautions implemented at the onset of symptoms. She was unable to explain the reasoning behind moving the infected resident instead of the roommate to a clean room. She thought the DON wanted all residents on isolation precautions on the same hall. When asked about admissions into the room with Resident #4, the ADON stated that the facility would not normally put anyone in there .possibly it was not communicated to (the person responsible for) Admissions. Review of the 12-11 Infection Log with the ADON on 5-1-12 at approximately 6:30 PM revealed that the onset date was noted as 12-28-11 instead of when the resident began having loose stools (12-16-11), when the first notation was made by the nurse in the Daily Skilled Nurse's Notes or when the physician was notified (12-19-11). Review of the mapping of infections to determine trends revealed that only one room was logged for the resident, though she had been in two during this review period. Resident #6 with [DIAGNOSES REDACTED]. Review of the Daily Skilled Nurse's Notes revealed the resident developed loose stools and was placed on contact isolation on 2/17/12. A stool specimen was collected and sent to the laboratory that day. On 2/18/12, the lab reported a positive[DIAGNOSES REDACTED] test. Not until 2/21/12 was treatment ordered for the[DIAGNOSES REDACTED]. Review of the Daily Skilled Nurse's Notes and the facility's Census List showed the resident was admitted to room [ROOM NUMBER], then transferred to room [ROOM NUMBER] the same day due to roommate concerns. In room [ROOM NUMBER], she had a roommate for three days (2/17, 2/18, and 2/19/12) despite the physician's orders [REDACTED]. On 2/19/12, the resident was moved from room [ROOM NUMBER] to room [ROOM NUMBER]. Her roommate remained in room [ROOM NUMBER]. During an interview beginning at 5 PM on 5-1-12, the ADON reviewed the medical record and confirmed the above information. Review of the 2-12 Infection Log with the ADON on 5-1-12 at approximately 5:30 PM revealed that the onset date was noted as 2-27-12 instead of when the resident began having loose stools (2-17-12) and was placed on contact precautions. No pathogen was identified on the log, though the resident had tested positive for[DIAGNOSES REDACTED]. Related [DIAGNOSES REDACTED]. Review of the mapping of infections to determine trends revealed that only one room was logged for the resident, though she had been in two during this review period. The ADON was unable to explain the reasoning behind moving the infected resident instead of the roommate to a clean room. She re-stated that the DON wanted all residents on isolation precautions on the same hall. However, review of the infection mapping revealed isolation precautions for gastrointestinal symptoms/C-Diff being maintained on all four halls. Resident #8 with [DIAGNOSES REDACTED]. Review of the hospital Transfer Discharge Summary with the ADON on 5-1-12 at 5:35 PM revealed that the resident was discharged on intravenous [MEDICATION NAME] and Zocyn to be discontinued on 12-9-11 (for treatment of [REDACTED]. The facility admitted the resident on [MEDICATION NAME] (to be stopped on 11-2-11) and contact precautions for[DIAGNOSES REDACTED]. Record review and interviews revealed that the facility failed to identify persistent signs and symptoms of[DIAGNOSES REDACTED] after the initial treatment and notify the physician in a timely manner so that an assessment could be completed to determine if further interventions were needed to treat the infection. Review of the Daily Skilled Nurse's Notes with the ADON revealed that the resident continued to have loose stools/diarrhea after the [MEDICATION NAME] was stopped (11-2-11) without notification of the physician until 11-12-11. A stool specimen was sent to the lab to be rechecked on 12-6-11. There was no evidence that the physician was notified of the negative results until at least 12-14-11 as evidenced by the run date on the report. There were no initials on the document to indicate that the physician/extender had reviewed the report. The resident was kept on isolation until contact precautions were discontinued on 12-14-11. During an interview on 5-1-12 beginning at 5:35 PM, the ADON reviewed the medical record and confirmed the above information. She was unable to explain why the physician had not been notified of continuing symptoms of[DIAGNOSES REDACTED] so the resident could be assessed for appropriate interventions as needed. Review of the Daily Skilled Nurse's Note revealed the resident contaminated his hands with feces and then contaminated his wound. Documentation also showed he contaminated his environment on 11/30/11 when drops of stool were noted on the floor, commode, and shower chair. Review of the physical therapy notes showed some documentation that the resident received therapy in his room. This documentation showed short distances ambulated a number of times. Other documentation, although the location was not specified, indicated the resident was out of his room for therapy: On 10/28/11 he ambulated 300 feet; on 11/11/11 he ambulated 200 feet; on 11/14/11 he ambulated 250 feet; and on 11/15/11 he ambulated 250 feet three times. There was no information to show what precautions were taken to protect other residents and the environment when the resident came out of his room for therapy. During an interview on 5-1-12 at 5:50 PM, the Rehab Manager stated she would contact the appropriate therapists to determine where the ambulation had been done with the resident. On 5-2-12, the Rehab Manager gave a written statement that the long distance ambulation was most likely performed out of the room. Their policy was to apply personal protective equipment to the resident and therapists and to keep any episodes contained. Anything the patient came in contact with was deep cleaned with disinfectant spray. During an interview on 5-2-12 at 11 AM, the Housekeeping and Maintenance Supervisor, in the presence of the chemical vendor representative, stated that 103 Neutral Disinfectant Cleaner had been used exclusively as the disinfectant in the building for deep cleaning all rooms and resident areas until approximately mid-April when bleach wipes had been purchased for cleaning isolation rooms. Resident #10 with a [DIAGNOSES REDACTED]. Review of 8-22-11 Physician/Extender Progress Notes on 5-1-12 at 3 PM revealed that the resident was placed on [MEDICATION NAME] for a vaginal yeast infection. Review of the Telephone Orders revealed that [MEDICATION NAME] and [MEDICATION NAME] were added on 8-25-11. Review of the computerized ADL Records on 5-1-12 at approximately 3:45 PM with Certified Nursing Assistant (CNA) #1 and the ADON revealed that the resident began having loose stools on 8-21-11. There was no evidence that the physician was notified until 8-26-11 when the physician ordered a stool test for[DIAGNOSES REDACTED]. Review of Daily Skilled Nurse's Notes revealed no documented diarrhea/loose stools until 8-28-11. The lab results provided on 8-27-11 were positive for[DIAGNOSES REDACTED]. [MEDICATION NAME] and contact precautions were ordered on [DATE] and the resident was moved to another room, leaving the roommate in the more contaminated area. There was no explanation for the five day delay in notification of the physician or another two day delay in ordering treatment and contact precautions found during the record review. During an interview on 5-1-12 beginning at 3 PM, the ADON reviewed the medical record and confirmed the above information. She stated that the physician should have been notified and precautions implemented at the onset of symptoms. She was unable to explain the reasoning behind moving the infected resident instead of the roommate to a clean room. At 3:15 PM, she and the Administrator noted that the DON wanted all residents requiring isolation precautions on the same hall. Review of the 9-11 Infection Log with the ADON revealed that the onset date of the infection was listed as 8-30-11 with no isolation precautions implemented. Review of the mapping of infections to determine trends revealed that only one room was logged for the resident, though she had been in two during this review period. Resident #12 with [DIAGNOSES REDACTED]. Record review and interviews revealed that the facility failed to identify signs and symptoms of[DIAGNOSES REDACTED] and notify the physician in a timely manner so that interventions could be implemented to treat the infection and prevent its' transmission. Review of the Daily Skilled Nurse's Notes with the ADON on 5-1-12 at 3:45 PM revealed that from 10-29-11 at 7 PM to 10-30 11 at 7 AM, the resident continues to have small, freq(uent) amounts loose stool. 10-28-11 documented Continent of all episodes, but was not specific. She had four loose stools in twelve hours on 10/30/11. On 10/31/11, the resident had diarrhea stools three times. A stool specimen was collected and sent to the laboratory. There was no evidence that the physician was notified until a physician's orders [REDACTED]. [MEDICATION NAME] was not ordered for treatment until 11/7/11. This physician's orders [REDACTED]. Contact precautions were ordered again on 11/10/11. There was no evidence in the record to indicate which date the precautions were implemented though the nurses' notes showed that the resident was on contact precautions on 11/9/11. Review of the computerized ADL Records on 5-1-12 at 4:15 PM with Certified Nursing Assistant (CNA) #1 and the ADON revealed that the resident began having loose stools on 10-28-11. There was no evidence that the physician was notified until 11-1-11, 4 days later. Review of the medical record showed no reasons for the delay in ordering treatment or for the delay in instituting contact precautions. During an interview on 5-1-12 beginning at 3:45 PM, the ADON reviewed the medical record and confirmed the above information. She stated that the physician should have been notified and precautions implemented at the onset of symptoms. She was unable to explain why this had not been done. The facility initially admitted Resident #5 on 10-21-11 with [DIAGNOSES REDACTED]. He was hospitalized from 11-11-11 through 11-22-11 for rectal bleeding. Upon readmission to the facility, the resident again suffered rectal bleeding and was hospitalized until 11-30-11. He was readmitted on contact precautions and [MEDICATION NAME] for seven days for treatment of [REDACTED]. Review of the Daily Skilled Nurse's Notes on 5-1-12 at approximately 12 PM with the ADON revealed that the resident had no further diarrhea/loose stools after completion of [MEDICATION NAME] on 12-7-11. Review of the computerized ADL Records on 5-1-12 at approximately 3:45 PM with Certified Nursing Assistant (CNA) #1 and the ADON revealed no documented loose stools after the medication was completed. Review of the Telephone Orders revealed that contact precautions were not discontinued until 12-20-11, 13 days later. During an interview on 5-1-12 beginning at approximately 12 PM, the ADON reviewed the medical record and confirmed the above information. She stated that the resident should have been taken off isolation when the medication was completed without further symptoms in evidence. During an interview on 5-1-12 at 10:15 AM, the Medical Director (and attending physician) stated he would expect to be notified immediately of signs and symptoms of[DIAGNOSES REDACTED] and the on-call physician/extender should be notified of the same on the weekend. If[DIAGNOSES REDACTED] was suspected, he would expect the facility to implement transmission-based precautions immediately, not to wait on lab reports. Review of the facility's policy and procedure for treatment of [REDACTED]. difficile were diarrhea - 3 loose stools in a 24 hour period; and abdominal pain or nausea and vomiting. When signs and symptoms of [DIAGNOSES REDACTED]icile are present then: 1. Isolate the resident from other residents that do not have [DIAGNOSES REDACTED]icile. Infection control practices must be implemented to including contact precautions and hand hygiene. Hand hygiene should include washing using soap and water. [DIAGNOSES REDACTED]icile spores are resistant to killing by alcohol. 2. Obtain order for to (sic) collect stool for lab. Staff was then directed to obtain the stool specimen, notify the physician with the results, and start the medications as ordered. Review of the facility's Contact Precautions policy and procedure revealed contact precautions were used for pathogens transmitted by direct resident contact or by contact with items in the resident's environment. BARRIERS INDICATED FOR CONTACT PRECAUTIONS The policy mandated the use of gloves when entering the room and while providing care to the resident. Gowns were to be worn if substantial contact with the resident, and/or environmental surfaces was anticipated. Gowns were to be removed before leaving the room and once the gown was removed clothing should not contact potentially contaminated environmental surfaces. If a resident left the room, precautions should be maintained to minimize the risk of transmission of microorganisms to other residents and contamination of environmental surfaces or equipment. Review of the Infection Control Logs and mapping of infections revealed that the logs contained incorrect/missing data. Residents were moved, some more than once, with only one location mapped. Compilation of infection information for 9-2011 showed one resident with[DIAGNOSES REDACTED]. In 10-2011, five residents were noted with[DIAGNOSES REDACTED]. Four of these are noted above. In 11-2011, six residents were noted with[DIAGNOSES REDACTED]. three of these are noted above. In 12-2011, five residents were noted with[DIAGNOSES REDACTED]. One of these is noted above. In 1-2012, one resident was list with[DIAGNOSES REDACTED]. In 2-2012, six residents were listed with gastrointestinal infections, five with[DIAGNOSES REDACTED]. Nine residents were mapped with gastointestinal infections. In 3-2012, one resident was list with[DIAGNOSES REDACTED]. The 4-2012 data was unavailable for review. There was no evidence that the local Regional Office of the Department of Health and Environmental Control was notified. During an interview on 5-1-12 at approximately 10:30 AM, the ADON reviewed the 9-11 Infection Control Log with the surveyor and verified that the entries on the log were by resident name, not by infection onset date, thus making it difficult to determine patterns/trends in a timely manner. She stated that she was responsible for the Infection Control Program and was made aware of infections by review of copies of physician's orders [REDACTED]. When asked why the entries in the log were not in sequence, the ADON stated, I got a pile of telephone orders and I enter them when I get a free moment. When asked if she had identified any patterns/trends, she stated she had not but that she had just been promoted to ADON and made responsible for Infection Control a couple of months previously. She stated she had received no formal training except for how to enter the information into the computer. It was just read the policies and learn as you go. She could not remember signing anything that stated her responsibilities to the infection control program. Review of the ADON's personnel file on 5-1-12 revealed no job description related to her current position or evidence of infection control training. A job description (signed 1-6-12) presented on 5-2-12 noted one of the Areas of Responsibility under Regulatory Compliance included: 7. Assure that the facility, through established systems is in compliance with infection control regulations. Be responsible for reporting to the DON and Administrator all the pertinent information for Quality Assurance in Infection Control. It was not specific as to duties and responsibilities to the program as was the job description in the Infection Control Policies and Procedures Manual. Review of the facility's infection control policies and procedures revealed that the requirements for reportable infections per the Centers for Disease Control and the South Carolina Department of Health and Environmental Control were not included. The contents of the manual were noted as reviewed and revised by the Administrator on 8-23-11, the acting Director of Nurses on 4-6-12, and by the Medical Director on 8-24-11. During an interview on 5-2-12 at 12:45 PM, the ADON was unaware of her duties in relation to reporting requirements. She stated, It would be either the Administrator or the DON. She was not aware of any documents showing what infections to report or to which agencies they should be reported. During an interview on 5-1-12 at 1 PM, the two housekeepers on duty stated that daily and terminal cleaning of isolation rooms, including those rooms of residents on contact precautions for[DIAGNOSES REDACTED], had been done using 103 Neutral Disinfectant Cleaner. Review of the manufacturer's information revealed content of ammonium chloride. Upon clarification, they stated that they had just gotten bleach wipes for use in these rooms and new procedures, which had been implemented 2-3 weeks previously. Two to three months prior to the survey, the Housekeepers stated that there had been seven or more residents on isolation at a time. They stated they had attended an infection control inservice in April. During an interview and observation of the laundry process on 5-1-12 at 1:15 PM, the Laundry Aide stated that personal laundry was washed on one of two cycles without bleach as per the signs on the washers. All other cycles for facility laundry used LL3000, a Liquid Laundry Destainer containing sodium hypochlorite. The Housekeeping/Maintenance Supervisor stated that the water temperature in the washers ranged from 110 to 140 degrees and that LL 3000 was not used in personal clothes. The chemical vendor was contacted and stated that if the water temperat | 2016-06-01 |