| 65 |
NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE |
445033 |
1414 COUNTY HOSPITAL RD |
NASHVILLE |
TN |
37218 |
2018-03-28 |
880 |
D |
1 |
0 |
8HII11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policies, medical record review, staff interview, and observation, the facility failed to ensure infection control measures related to the dressing change of a peripherally inserted intravenous catheter (PICC) for 1 of 3 residents (Resident #7) reviewed with PICC lines; and failed to properly utilize hand hygiene during medication administration for 1 of 4 residents (Resident #15) observed for medication administration. Failing to change PICC line dressings had the potential to affect eight residents identified with PICC lines; failing to use hand hygiene could increase the risk of infection, and had the potential to affect all 176 residents in the facility. Findings include: Review of facility Infusion Therapy Procedures dated 2011, was reviewed and revealed .PICC and Midline Catheter dressing changes must be completed at minimum every seven days. Change immediately if: loose, not occlusive, moisture accumulation, drainage, redness, or irritation. Initial dressings will be changed PRN (as needed) if saturated, and 24-48 hours post insertion of Midlines, PICC's . if there is gauze present under the dressing or drainage is noted . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #7 was alert, oriented, and independent with all activities of daily living except assistance of 1 to be off the unit. Medical record review of the nursing admission assessment dated [DATE] revealed the resident was admitted with a right upper extremity PICC line. Medical record review of physician progress notes [REDACTED]. Medical record review of physician orders [REDACTED]. Medical record review of a Daily Skilled Nursing Note dated 12/08/17 revealed .central line dressing scheduled as per staff to be changed . Medical record review of Medication Administration Records, (MAR), dated 11/30/17 through 12/10/17 (11 days) revealed no evidence of a dressing change to the PICC line. Medical record review of Physician order [REDACTED].#7 revealed .discontinue PICC line and reinsert new Midline catheter . Review of a procedure form for Resident #7 dated 12/10/17 revealed .the patient PICC line was out 7 centimeters and the dressing was loose on three sides. A Midline catheter was inserted into the left upper arm with a dressing applied . Medical record review of Physician order [REDACTED]. Medical record review of the MAR for Resident #7 dated from 12/11/17 through 12/26/17 (17 days) revealed no evidence of a dressing change to the Midline catheter. Medical record review of the Comprehensive Care Plan dated 12/11/17, revealed the .resident as at risk for complications related to the use of IV (intravenous) fluids and /or medications with a right upper arm PICC line . Interventions included .apply and check IV site treatment/dressings as ordered . Interview with the Director of Nursing (DON) on 3/28/18 at 2:30 PM confirmed the resident was admitted with a PICC line. Further interview revealed the PICC line became misplaced and a new Midline catheter was placed to continue the antibiotic administration. The DON confirmed the facility failed to have documentation of a dressing change to the PICC line and Midline catheter every seven days as per the facility policy. Review of the facility Medication Administration General Guidelines dated 2007 revealed, .hands are washed with soap and water and gloves applied before administration of topical, ophthalmic, otic, [MEDICATION NAME], enteral, rectal, and vaginal medications. Hand are washed with soap and water again after administration and with any resident contact. Antimicrobial sanitizer may be used in place of soap and water as allowed per state nursing regulations and facility policy . Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of medication administration on 3/27/18 at 8:50 AM revealed Licensed Practical Nurse (LPN) #6 entering the isolation room for Resident #15. LPN #6 donned personal protective equipment (PPE) to include a mask, gown, and gloves. With the help of Rehab #2 the resident was repositioned to allow better access to the resident gastronomy tub ([DEVICE]). LPN #6 removed gloves, donned new gloves, and assessed the [DEVICE] for placement and residual tube feed, changed gloves and administered several medications per the [DEVICE]. LPN #6 then changed gloves and administered prescription eye drops in each eye. LPN #6 took off gloves and reached under the PPE gown and took a large bore needle from a uniform pocket, donned gloves and used the needle to puncture two fish oil capsules, and place the liquid from the capsules in a medication cup. After changing gloves, LPN #6 administered the fish oil through the [DEVICE], changed gloves and administered a subcutaneous injection into the resident's abdomen. After changing gloves, LPN #6 administered a second drop of the prescription eye drop to each of the resident's eyes. LPN #6 then removed the PPE and gloves, washed hands with soap and water before exiting the room. The hand washing prior to exit was the only time LPN #6 completed hand washing or hand hygiene for the entire medication administration. Interview with LPN #6 on 3/27/18 at 9:30 AM on the second-floor hallway confirmed hand hygiene, to include hand washing or alcohol rub, was not used during the medication administration with Resident #15. Further interview revealed LPN#6 was unsure of the facility policy for hand hygiene. Interview with the DON on 3/28/18 at 5:10 PM in the facility Conference Room revealed staff were expected to wash hands or use alcohol rub any time gloves were worn and removed, before and after injections, and before eye drops and [DEVICE] medications. Further interview confirmed nursing staff should not remove items from pockets while in an isolation room. |
2020-09-01 |