cms_TN: 55
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 55 | NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER | 445030 | 5010 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2019-06-05 | 880 | D | 0 | 1 | PCFO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed when 3 of 8 (Certified Nursing Assistant (CNA) #1, Physical Therapist Assistant (PTA) #1, and Licensed Practical Nurse (LPN) #1) staff members failed to perform appropriate hand hygiene during contact isolation for Resident #182 and wound care for Resident #181. The findings include: 1. The facility's HANDWASHING policy with a revision date of 4/23/18 documented, .Hand hygiene has been cited frequently as the single most important practice to reduce the transmission of infectious agents in healthcare settings, and is an essential element of Standard Precautions .in the case of spore forming organisms such as[DIAGNOSES REDACTED]icile ([MEDICAL CONDITION]) .require soap and water with friction .PR[NAME]EDURE .Wash hands before and after contact with each patient .and before and after removal of gloves . 2. Medical record review revealed Resident #182 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. diff), [MEDICAL CONDITION] Stage 3, Traumatic Subdural Hemorrhage, Diabetes, [MEDICAL CONDITIONS], and Depression. The physician's orders [REDACTED].Strict Isolation-All services provided in room .for [MEDICAL CONDITION] . Observations in Resident #182's room on 6/3/19 at 12:19 PM revealed CNA #1 delivered ice to the resident, removed the gown and gloves, used hand sanitizer, and exited the room. Observations outside Resident #182's room on 6/4/19 at 8:15 AM revealed PTA #1 donned a gown, mask and gloves, and entered Resident #182's room. PTA #1 remained in the room for 37 minutes and exited the room at 8:52 AM without performing hand hygiene. Interview with PTA #1 on 6/4/19 at 8:52 AM outside Resident #182's room, PTA #1 was asked if she washed her hands before she came out of the room. PTA #1 stated, I don't like to use their bathroom . PTA #1 then used the hand sanitizing gel that was on the isolation kit outside the door, and then walked to the therapy gym. Interview with Registered Nurse (RN) #1 on 6/5/19 at 8:03 AM in the conference room, RN #1 was asked why Resident #182 was in isolation. RN #1 stated, [DIAGNOSES REDACTED]. RN #1 was asked what the staff were supposed to do when they entered and exited Resident #182's room. RN #1 stated, They hand wash .the hand gel stuff don't work with the [MEDICAL CONDITION]. They are supposed to wash hands with soap and water coming out of the room. Interview with the Director of Nursing (DON) on 6/5/19 at 8:42 AM in the conference room, the DON was asked if the staff should perform hand hygiene using hand sanitizing gel after they left Resident #182's room. The DON stated, It's not appropriate for the [MEDICAL CONDITION]. 3. Medical record review revealed Resident #181 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Wound Management notes dated 6/1/19 revealed Resident #181 had extensive [DIAGNOSES REDACTED] (a disease in which calcium accumulates in the small blood vessels of the fat and skin tissue) ulcers, 3 to the left upper arm, 3 to the right upper arm, 1 to the right thumb, 1 to the right hand, and 1 to the right wrist. Observations in Resident #181's room on 6/4/19 at 3:21 PM revealed the following: LPN #1 removed the soiled dressing from Resident #181's right upper arm, cleaned the posterior upper wounds with saline soaked gauze, and then used a cotton swab to apply [MEDICATION NAME] gel, using the same gloves. LPN #1 did not perform hand hygiene between cleaning the wound and applying the clean treatment. LPN #1 placed a saline soaked gauze on the wound to the anterior right upper arm, still wearing the same gloves. LPN #1 did not change gloves or wash her hands between different wounds. LPN #1 removed her gloves, and adjusted the thermostat on the wall. LPN #1 did not perform hand hygiene after removing the soiled gloves. LPN #1 cleaned the [MEDICATION NAME] gel from Resident #181's posterior upper arm wounds with saline soaked gauze, and applied [MEDICATION NAME] One (a dressing used for painful wound management that prevents the outer dressing from sticking to the wound bed) and [MEDICATION NAME] Extra (a moisture retention dressing) using the same gloves. LPN #1 did not change gloves or perform hand hygiene between cleaning the wound and applying clean dressings. LPN #1 removed her gloves, applied clean gloves, and removed the dressing from Resident #181's right lower arm. LPN #1 did not wash her hands between glove changes and between different wounds. LPN #1 cleaned the wounds to Resident #181's right posterior lower arm using saline soaked gauze and then applied [MEDICATION NAME] One, [MEDICATION NAME] Extra, (abdominal pads (ABD) used for large wounds or wounds needing high absorbency), and conforming gauze dressings using the same gloves. LPN #1 did not change gloves or perform hand hygiene between cleaning the wound and applying clean dressings. LPN #1 removed the dressings from Resident #181's right wrist and hand, cleaned the wounds with saline soaked gauze, and applied [MEDICATION NAME] One dressing. LPN #1 did not change gloves or perform hand hygiene between cleaning the wound and applying clean dressings. LPN #1 changed her gloves without performing hand hygiene, and applied [MEDICATION NAME] Extra, ABD pads, and conforming gauze to Resident #181's right wrist. LPN #1 did not perform hand hygiene between glove changes. LPN #1 removed the dressing from Resident #181's left upper arm and changed her gloves without performing hand hygiene. LPN #1 cleaned the wounds to the left upper arm with saline soaked gauze, applied [MEDICATION NAME] One, [MEDICATION NAME] Extra, and ABD pad dressings, and wrapped the right upper arm with gauze. LPN #1 did not change gloves or perform hand hygiene between cleaning the wound and applying clean dressings. Interview with the DON on 6/5/19 at 8:42 AM in the conference room, the DON was asked when staff should perform hand hygiene during wound care. The DON stated, In between clean and dirty, I want them to be washing their hands and changing their gloves. The DON was asked if they were supposed to wash their hands when they changed gloves. The DON stated, Yes. | 2020-09-01 |