| 8304 |
AGAPE REHABILITATION OF CONWAY |
425391 |
2320 HIGHWAY 378 |
CONWAY |
SC |
29527 |
2012-05-02 |
520 |
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 review of quality improvement documents, record reviews, and interviews, the facility failed to identify ongoing quality deficiencies related to monitoring and implementing infection control policies and procedures. The QAA Committee failed to conduct ongoing reviews of the processes involved in infection control surveillance and monitoring. Staff failed to follow a plan of action established in November 2011 related to ongoing monitoring of compliance with infection control procedures. The findings included: During an interview on 5-1-12 at 11:45 AM, the Administrator stated that the Infection Control Committee was not a separate entity but was part of the QAA Committee. He presented an action plan for November 2011 that noted the opportunity for improvement as Proper infection control methods that were in place before are currently not in place. He stated that this was based on general observations of resident care. Steps to correct/improve included: Inservices to be provided to nursing staff by 12-7-11; Compliance rounds to be done daily; and random audits to be done to ensure that infection control procedures were followed. Review of information provided by the facility staff on 5-2-12 revealed that 12 nurses and 1 CNA were inserviced on basic infection control on 11-15-11. Twelve CNAs and two nurses attended an inservice on 11-28-11 on infection control: room set-up/isolation equipment/drawers. Compliance rounds were only documented as completed twice (12-14-11 with 6 residents on isolation, 12-20-11 with 4 residents on isolation). Although additional information regarding completion of the plan and ongoing monitoring/audits were requested, none were provided. Additional disservice records were provided but not all departments/staff were in attendance. There was no evidence that the committee reviewed the implementation of the plan, monitored the outcome, or made needed revisions. On 5-2-12, review of the facility policy entitled Infection Control Committee - Duties and Responsibilities (Revised June, 2010) revealed that The Infection Control Committee will oversee the use of proper prevention and control measures, and will help identify, investigate and control outbreaks of infectious diseases within the facility. The Committee failed to identify concerns and develop and implement a plan of action related to failure of staff to notify the physician with onset of signs and symptoms of [MEDICAL CONDITION] in high risk residents. The Committee failed to identify concerns and develop and implement a plan of action related to failure to follow established and/or effective procedures for tracking and trending infections. During an interview on 5-2-12 at 11:15 AM, the Medical Director stated he participated in QAA meeting on a quarterly basis, the last one being one or two months ago. He stated the DON reviewed trends for the previous year related to numbers of infections. He stated he was aware of the increase in the number of residents with [MEDICAL CONDITION] before the first of the year and in February-3 or 4 at a time. He was not aware that there had been nine gastrointestinal/[MEDICAL CONDITION] infections mapped for the month of February. The facility staff had not spoken with him regarding specific interventions other than isolation and strict handwashing. He thought ongoing training worked but was unaware that the QAA plan for infection control had not been fully implemented. When asked, the Medical Director stated, I guess I know outbreaks have to be reported. Have they done it? Cross Refer: CFR 483.65 Infection Control F441 The facility failed to notify the physician of the onset of gastrointestinal signs and symptoms of [MEDICAL CONDITIONS] in a timely manner for four of nine sampled residents reviewed with [MEDICAL CONDITION] (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 [MEDICAL CONDITION] (Residents #1, #4, #6, #8, #10, and #12). The Infection Preventionist (IP) was unaware 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 [MEDICAL CONDITION] 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 [MEDICAL CONDITION]. Cross Refer: CFR 483.10(b)(11) Notification of Changes F157 related to facility failure to notify the attending physician in a timely manner of changes in residents' physical conditions which required intervention/changes in treatment. The physician was not notified of the onset of gastrointestinal signs and symptoms of [MEDICAL CONDITIONS] in a timely manner for four of nine sampled residents reviewed with [MEDICAL CONDITION] (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. Cross Refer: CFR 483.75 Administration F490 related to facility administration failure to ensure that policies and procedures were in place/followed to prevent, recognize, and control the onset and spread of infection within the facility. Cross Refer: CFR 483.75(i) Medical Director F501 related to Medical Director failure to coordinate medical care in the facility to ensure that resident care was consistent with established infection control policies and procedures. The immediacy was removed prior to exit from the facility on 5-2-12 after (1) review of the ongoing training content and participation and staff interviews related to that training were conducted, (2) evidence was presented that the medical record audits (with findings) were completed and any notifications/interventions implemented, (3) basic training was provided to the Infection Preventionist related to job duties/responsibilities, (4) the laundry was checked to ensure that it was being hygienically cleaned (5) job desciptions, duties and responsibilities were reviewed with staff members responsible for infection control data collection and analyzation. CFR 483.75 Quality Assessment and Assurance (QAA) F520 was lowered to a scope and severity of F. |
2016-06-01 |