| 20 |
HERITAGE PARK HEALTHCARE AND REHABILITATION |
465003 |
2700 WEST 5600 SOUTH |
ROY |
UT |
84067 |
2019-02-21 |
880 |
E |
1 |
1 |
R8D511 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, it was determined that the facility failed to establish and maintain an Infection Prevention and Control Program (IPCP) designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, staff did not place signage outside a resident's room identifying the need for transmission-based precautions, two resident rooms had signage that had fallen off the wall. Multiple rooms of residents with respiratory illness with resistant bacteria, had PPE (personal protective equipment) at the resident door, had garbage cans that were spilling over with PPE in the resident room and/or garbage cans that were within three feet of the resident when doffing PPE in resident rooms. Additionally, cross contamination was observed in the dining room. Resident identifiers: 9, 10, 15, 57 and 58. Findings include: 1. Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/20/19 at 9:25 AM, an observation was made of resident 9's pressure ulcer dressing change. When the dressing change was completed, an observation was made of facility staff and this surveyor, taking off PPE and placing it in the resident's regular garbage receptacle near the door. The garbage receptacle was observed to have multiple items of PPE and spilling over the top, thus allowing gloves and masks to fall to the floor. 2. Resident 10 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/19/19 at 11:10 AM, an interview was conducted with resident 10's daughter. An observation was made of resident 10's daughter in his room without the use of PPE. Resident 10's daughter was sitting at his side while in his recliner. Resident 10's daughter was observed to be touching resident 10, the arm of the recliner, the top of the overbed table and other surfaces in resident 10's room. Additionally, an observation was made of the sign that had hung on the wall near resident 10's room, the sign had fallen down to the floor and was stuck in the moulding along the wall, thus allowing anyone to enter resident 10's room without any knowledge to see the nurse prior to entering the room. On 2/19/19 at 11:20 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 10's daughter was in school to become an Occupational Therapist, had done her homework on the CRAB infection, and that the risk of her getting sick was really very low. LPN 1 stated that resident 10's daughter understood the risks and and that was why she was in the room without PPE. LPN 1 stated that resident 10's daughter, does it all the time, it's her choice. On 2/19/19 at 12:27 PM, an observation was made of resident 10 while in the therapy room. Resident 10 was observed to have to PPE covering his mouth. On 2/20/19 at 11:50 AM, an observation was made of resident 10's daughter in his room without the use of PPE. Resident 10's daughter was observed to be providing cares to resident 10. Resident 10's daughter was observed to be touching resident 10, the surfaces of resident 10's bed, bed sheets, wheelchair and other surfaces in resident 10's room. On 2/20/19 at 12:22 PM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that they had educated resident 10's daughter multiple times regarding the use of PPE and the importance of using it. The facility DON stated that a sign had been placed on all isolation rooms and did not know it had fallen off the wall. The facility DON stated that resident 10 was ok to go to therapy without PPE if his stoma was covered. The facility DON stated that she did not know if the CRAB infection were to be spread if resident 10 coughed or sneezed during therapy. The facility DON stated that resident 10's CRAB infection was colonized and that they had obtained three cultures, two being negative for CRAB and one being positive for CRAB. The facility DON stated that they were trying to get three consecutive cultures being negative for the CRAB before taking resident 10 off isolation precautions. Documentation was requested from the facility DON showing that resident 10's CRAB infection was colonized. (NOTE: No documentation could be located in the medical record to show that resident 10's CRAB infection was colonized. No additional documentation was provided by the facility DON to show that resident 10's CRAB infection was colonized.) 3. Resident 15 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/19/19 at 1:21 PM, an observation was made of resident 15's wife in his room without the use of any PPE. Additionally, there was no sign on resident 15's door or wall near his door to alert visitor's to see the nurse prior to entering resident 15's room. On 2/20/19 at 11:11 AM, an observation was made of resident 15's wife again in his room without the use of any PPE. On 2/20/19 at 12:22 PM, an interview was conducted with the facility DON. The facility DON stated that they had educated resident 15's wife multiple times regarding the use of PPE while in the facility. The facility DON stated that a sign had been placed on all isolation rooms and did not know where the sign that was on resident 15's wall had gone. 4. Resident 57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/20/19 at 8:41 AM, an observation was made of resident 57's pressure ulcer wound treatment. An observation was made of facility staff and this surveyor, taking off PPE and placing it in the resident's regular garbage receptacle near resident 57's bed within 3 feet of resident 57's personal space. 5. Resident 58 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/19/19 at 2:38 PM, an interview was conducted with resident 58. On 2/19/19 at 2:38 PM, an observation was made of resident 58 sitting in her chair next to her table. An observation was made of resident 58's regular garbage receptacle sitting right next to resident 58. This surveyor had to take off PPE, bend over to throw the PPE in the trash receptacle next to resident 58. On 2/20/19 at 12:22 AM, an interview was conducted with the facility DON. The facility DON stated that no red biohazard bags were needed per the CDC (Center for Disease Control) guidelines unless there was blood or other resident fluid that was able to be wrung out. Then biohazard bags were necessary for those bodily fluids. The facility DON stated that the garbage was to be taken out each time that PPE was placed in the garbage by facility staff. The facility DON stated that they could get other garbage receptacles in the rooms near the doorways to throw the PPE away. The Guidance for the Selection and Use of PPE in Healthcare Settings by the CDC, revealed that the PPE as defined by the Occupational Safety and Health (OSHA) Administration is specialized clothing or equipment worn by an employee for protection against infectious materials. The Guidance additionally revealed that the PPE should be removed at doorway before leaving patient room or in anteroom. 6. On 2/19/19, the following observations were made during lunch service in the dining room located within the C hallway. a. At 12:15 PM, the Concierge was observed to assist with delivering meal trays to residents throughout the dining room. b. At 12:19 PM, the Concierge was observed to cut up food for a resident using the resident's silverware. c. At 12:25 PM, the Concierge was observed to hold another resident's straw and guide the straw to the resident's mouth. (Note: No observations were made of the Concierge washing or sanitizing her hands between assisting residents.) On 2/21/19 at 8:40 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated during meal service, hands should have been washed and sanitized after delivering each tray, between feeding residents, and after touching anything. On 2/21/19 at 11:01 AM, an interview was conducted with the Concierge. The Concierge stated staff members carried small containers of hand sanitizer in their pockets. The Concierge further stated staff were expected to to sanitize their hands after passing each tray and wash their hands after passing three trays. In addition, the Concierge stated hands should have been sanitized after cutting up food for a resident. On 2/21/19 11:12 AM, an interview was conducted with the Director of Nursing (DON). The DON stated during meal service, staff should have been washing their hands after touching a resident and in between providing care for residents. |
2020-09-01 |