| 7 |
SEA VIEW NURSING HOME |
485000 |
7500 BOLONGO BAY |
ST THOMAS |
VI |
802 |
2010-08-25 |
441 |
L |
0 |
1 |
MZE911 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observations of the facility environment, observation of nursing practices including blood glucose monitoring practices, medication administration procedures, storage of biologicals, storage of patient care equipment and products, wound care treatments, as well as information revealed in resident and staff interviews, and facility policies and procedures, it was determined that the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. The findings are pervasive and systemic and have the potential to affect all residents on many levels and constitutes Immediate Jeopardy. The Findings are: 1. During the general tour conducted of the facility on 8/19/10 the following was observed: a) A storage room, identified by nursing as the clean utility room contained several metal shelves. An old, dirty mattress was on the floor and propped against one of these shelves. According to the nurse accompanying the surveyor on tour, We sometimes have used that mattress for patients in the past. I don't know why it's in here or when it was last used. Several plastic expandable air mattresses were observed on the top shelf rack. One half of this shelf was labled Dirty Mattresses, the other half contained several mattresses which the nurse identified as clean. Another shelf contained several packages of adult Attends briefs. Two of the packages were opened and exposed to air, 10 individual briefs were not enclosed in packaging, but lay directly on the shelf. Dust was visible on this shelf. A large torn, plastic bag containing air mattresses was also observed on this shelf. A layer of dust was visible on the plastic bag. The mattresses were identified by the nurse as clean air mattresses. b) The medication room contained a refrigerator identified as the medication refrigerator. When inspected, the refrigerator thermometer showed a measurement of 60 degrees Farenheit. The contents of this refrigerator included three 10 cc vials of Insulin, [MEDICATION NAME] 100u/ML, [MEDICATION NAME] 70/30 100 Units/ml. and Insulin [MEDICATION NAME] R. Each of these vials were opened and according to the RN in attendance, were currently being used for medication administration. An uncovered bowl of applesauce, which according to the nurse, is generally used for medication administration was observed on a shelf of the refrigerator c) A dirty, 16 ounce plastic alcohol bottle containing a green colored liquid which the nurse described as the solution the nursing staff uses to cleanse the glucose monitors was observed on the counter of a cabinet. The label on the bottle was dirty. The label was dated 3/30/10. d) 3 large (lb.) red plastic jars containing Protein Whey powder were observed on a counter. In front of these were 3 smaller plastic bottles, (approximately 1000 cc containers) , with dirty labels containing protein whey powder. According to the nurse and dietician interviewed immediately following this observation, The protein whey is is received by the facility in the large containers and the nurses fill the smaller bottles with the Protein Whey powder each morning. Both the nurse and Dietitician admitted that there was no specific procedure for sanitizing the smaller plastic Bolles before they are filled or re-filled. 2. A Registered Nurse was observed administering medications on 8/20/10. During this observation the nurse was observed to not sanitize her hands either by handwashing or by use of a [MEDICATION NAME] gel sanitizer before and after each resident dose. The nurse was observed to drop a vial of medication onto the floor, to pick up the medication vial From the floor and to place the vial back into the medication cart. She was not observed to sanitize the vial before replacing it on the cart. She was not observed to wash her hands after picking up the vial from the floor, nor was she observed to wash or sanitize her hands before giving the next medication dose. 3. Two nurses, an LPN and an RN were observed performing the narcotic count on 8/20/10, at 3:45 P.M. The nurse (LPN) counting the medications was observed to spill several tablets of a medication onto the medication cart, pick up the spilled tablets with her bare hands and to put those tablets back into the medication vial. 4. During the tour of the medication room conducted on 8/19/2010, the Director of Nursing (DON) reported to the surveyor that one Glucometer, one container of test strips, and one lancet Pen device is used to test the blood glucose level of all the diabetic residents in the facility. The Ultra One Touch bottle, which was in a tray with the Glucometer, had a red blood smeared stain on it. The Director of Nursing (DON), identified a 16 oz dirty, white plastic bottle, (which upon observation looked like a used Rubbing Alcohol bottle), as the container used to hold the disinfectant solution that is used to clean the blood glucose testing equipment. Written in black on the bottle was Disinfectant Cleaner , there was no other labeling on the bottle. The date on the bottle, also written in black, read 3/30/10. When the Director of Nursing (DON) was asked, who prepares this solution? She replied, it is prepared by the Maintenance Director. 5. On August 19, 2010 at 4:20 p.m., a Registered Nurse (RN) was observed performing a fingerstick on resident #1. The nurse brought a plastic tray that contained a sharps container, Insulin syringes, the glucometer, lancet pen, 2x2 uncovered white gauzes, 2x2 alcohol pads, and a specimen container that had a clear green liquid with a yellow paper label affixed to it that read disinfectant cleaner. During the procedure, the nurse was observed to remove a test strip from a blood smeard container and to use the strip for blood sampling of the resident. 6. On August 19 2010, between 4:50 p.m. and 5:15 p.m., immediately following resident #1's blood glucose testing, the Registered Nurse (RN) was observed to carry the same equipment into resident #5's room and perform his blood glucose test. 7. During an interview conducted on the morning of the 8/23/10 with the facility ' s Maintenance Director, the Maintenance Director acknowledged that he prepares the solution used by the nursing staff to clean the glucose monitoring equipment. When asked how he prepares the solution? He stated I usually mix half and half: Half solution of DC Forward, a Disinfectant/Bactericidal liquid, and half water, then I pour it into the small 16 oz bottle for the nurses. He continued by stating, that the same solution is used for cleaning/disinfecting wheelchairs, the glucose monitor, tables and emesis basins. He stated that the decision as to whether the ? and ? proportion is used depends on the size of the equipment; if the area is large, then 3 quarts water to 1 quart solution is used. This method of cleaning equipment contradicts the manufacturer ' s instructions for the use of the cleaning solution, and does not ensure proper sanitization or disinfection. 8. On 8/23/10 at 1:30 p.m, an observation was made of an RN staff nurse conducting a fingerstick. She was observed to check the doctor ' s orders, gather the shared glucose monitoring equipment, wash her hands, and put on gloves. She was observed to wipe the exterior of the glucometer and the opening to the lancet Pen device using gauze that had been immersed into a green liquid, inside of a specimen container. After obtaining the blood glucose level of the resident, she disposed of the lancet in a Sharps container and threw away the test strip. After washing her hands, she returned the equipment to the tray and carried it back to the Medication room. During an on-the-spot interview, she was asked how long had she been using the single glucometer and lancing pen for more than one resident? She stated that she has been working at the facility for 2 years and for the past 2 years it was always done in the same way. When she was asked, how long has she been sanitizing the equipment using this method? She stated that this method of sanitizing has been used at the facility for about 1 year. She stated that the mixture is done by the Maintenance Director, and provided to them approximately 2 -3 times per week. When asked specifically about what type of container is used, she acknowledged that the 16 oz Alcohol bottle was used until the recent change to the specimen container. 9. During an interview conducted on the afternoon of the 8/24/10 in the resident ' s library, with one of the In-service Instructor ' s , the in-serviice instructor acknowledged that no specific inservice training had been given nursing staff related to sanitizing or disinfecting the glucose testing equipment (glucometer and Pen). The facility ' s policy and procedure on Glucometer Cleaning, with revision date of 3/29/2010 reads: Procedure for Cleaning: 1. Clean exterior surface of monitor and pen, after each patient with damp gauze and a facility approved disinfectant 2. Glucometer must be turned off before cleaning 3. Do not use solvents These instructions are inconsistent with the manufacturer ' s recommendations which are as follows: OneTouch Ultra 2: Blood Glucose Monitoring System The manufacturer ' s directions for cleaning the meter, OneTouch UltraSoft Blood Sampler and One touch UltraClear Cap: To clean these items, wipe them with a soft cloth dampened with water and mild detergent. - Do not use alcohol or other solvent to clean the meter. - Do not immerse the OneTouch UltraSoft Blood Sampler in any liquid. - To disinfect these items, prepare a solution of one part household bleach to ten parts water. 10. Glucose Monitoring practices of an LPN obtaining blood samples for four residents was observed on 8/20/10 at 11:40 A.M. During these performances , the following was observed: a) After obtaining a blood sample and measurement reading, the nurse was observed to place an uncleaned pen device onto the resident's unprotected bedside table , observed to pour a disinfectant solution used to cleanse the monitor onto a 4x4 guaze from a urine specimen cup, and to use this guaze to swab both the lancet pen device and the face of the monitor. b) After obtaining a blood sample the nurse was observed to obtain a disinfectant solution from a urine specimen cup, poured a small amount onto a 4x4 guaze and used this guaze to swab the pen device and glucose monitor. c) The nurse obtained a lancet from the vial containing lancets. While attempting to insert the lancet into the lancet pen device, The nurse dropped the unprotected lancet onto the the resident's bed, picked up the lancet, inserted it into the pen and punctured the resident's finger; a disinfectant solution, used to cleanse the monitor, was poured onto a 4x4 guaze pad from a urine specimen cup. d) The nurse was observed to enter the resident's room, wash hands, and to don gloves. The nurse placed a monitoring strip into the glucose monitor. The monitor fell into a plastic supply tray. After retrieving the monitor with the stirp still attached, the nurse was observed to pick up the lancet puncture device. The puncture device did not have a protective cap. The nurse attemepted to put the lancet into the puncture device but dropped the lancet onto the resident's legs. She was observed to pick up the lancet. insert it into the lancet pen and proceeded to perform the puncture. e) An LPN was Observed to prepare for and perform a Stage 3 Sacral wound treatment on 8/24/10 at 3:40 P.M. A CNA ( Certified Nursing Assistant) was in attendance at the resident's bedside. In preparation, the nurse removed a roll of tape from the treatment cart, cut several strips of tape from the roll and stuck the cut strips to the resident's bedside table. The nurse was then observed to take a Chux pad was from the CNA assisting with the treatment, and obtained a used pair of scissors from the wound treatment cart to cut the Chux in half. One half of the Chux was placed onto the resident's bedside table. Following these steps, the nurse proceeded to the resident's bathroom to wash her hands. After donning gloves, the nurse removed a bottle of Normal Saline from the top of the treatment cart, opened the Normal Saline and placed the bottle onto the Chux draped bedside table. Several sterile guaze (4x4's) were added to the Chux pad. The nurse poured Normal Saline onto the guaze, removed a box of gloves from the treatment cart, and placed the box onto the Chux draped table. A clear plastic bag taken from the treatment cart , was taped onto the resident's bedrail. The nurse was observed to remove her gloves and proceeded to the bathroom to wash her hands. After returning to the resident's bedside, the assisting CNA and the nurse re- positioned the resident, and the nurse removed the resident's Attends brief. Fecal matter was observed on the Attends brief. The soiled Attends brief was placed into the plastic bag hanging on the residents bedrail. Old dressings, saturated with purulent drainage, were removed from the wound site and discarded into the clear plastic bag taped to the resident's bed. The nurse stopped the treatment , cleansed the resident's buttocks and entered the residents's bathroom where she was observed to wash her hands for 8 seconds. Upon returning to the resident, the nurse put on a new pair of gloves, poured Normal Saline onto the Chux draping the bedside table, picked up a previously Normal Saline soaked guaze and began to use to the guaze ( in a patting motion) to soak up the Normal Saline just poured onto the Chux. The nurse proceeded to use this guaze to cleanse the sacral wound. This procedure was repeated six times. Following this cleansing method, the nurese was observed to pick up a previously soaked Normal Saline guaze, dip it into the pool of Normal Saline previously poured onto the Chux pad and to use this guaze to pack the wound site. She was observed to cover the site with a dry guaze taken from the Chux pad. After taping the site, the nurse removed her gloves and then entered the resident' bathroom to wash her hands. She was observed to wash hands for 6 seconds. The CNA, who was not wearing gloves, disposed of the clear plastic bag which contained the old dressings, and soiled Attends brief. During this procedure, the nurse was not observed to wash hands effectively, was not observed to maintain aseptic technique when preparing the field, was not observed to maintain asepsis when cleansing the wound site or with packing of the wound, did not change gloves and wash her hands after cleaning the site and before the application of new dressings and the CNA was not observed to glove when handling contaminated items. Additionally, the nurse was not observed to sanitize the used scissors before replacing it to the wound cart. The treatment cart was identified as the cart containing all supplies used with all residents requiring wound care. On 08/23/2010 @ approximately 2:20 p.m., the dressing change of resident #1's right heel was observed. The nurse conducting the dressing change was observed to check the doctor ' s order prior to starting, sanitized her hands and then gathered the supplies for the dressing change. As the old dressing was being removed, the resident groaned audibly two times. The Registered Nurse (RN) performing the dressing change did not stop the procedure. She did, however, acknowledge the resident ' s pain by saying to her I ' m sorry honey and continued with the wound care. She did not assess the severity of the resident ' s pain and no pain medication was offered. When the surveyor asked the RN if the resident had received pain medication prior to the dressing change she replied, I am not entirely sure she has pain medication ordered. After removing the soiled dressing, the nurse removed her gloves, donned clean gloves, cleansed the right heel with a gauze soaked with normal saline, and then covered the wound with 4x4 gauze. She placed the resident ' s heel on the bed, and removed her gloves. She then, stepped out of the room into the corridor and went to the treatment cart where she removed a roll of kerlix gauze. She re-entered the resident ' s room, donned clean gloves and wrapped the resident ' s heel with the kerlix. The nurse placed the soiled dressing and the gauzed used to clean the wound in the resident ' s garbage untagged. The nurse did not wash or sanitize her hands after cleansing the resident ' s wound, before or after going to treatment cart for the additional supplies, or before securing the dressing. An interview was conducted immediately following the dressing change. The nurse was asked why she did not stop, assess or offer the resident pain medication when the resident clearly was experiencing pain? She replied, She only does that when you are messing with her foot. The nurse was asked when she would offer a resident pain medication. She answered, I would give it, if she asked for it. Review of the Physician orders [REDACTED]. 1. Tylenol 650 mg P.O. Q4HR PRN for pain or Temp 100. 2. [MEDICATION NAME] 5/500 mg P.O. Q4HR PRN Review of the facility ' s Policy and Procedures on Treatment/Dressing Changes reads: Ask if the resident would like pain medication prior to treatment The facility ' s Policy and Procedure on Wound Care Protocol reveals that there are instructions for providing pain medication for residents with Stage III Decubitus only . These instructions indicate the nurse is to : Medicate for pain relief if indicated prior to treatment A review of the facility's new hire personnel health records revealed that 6 of 10 health records lacked evidence of current screening for [DIAGNOSES REDACTED] (Mantoux/ PPD testing). i) On 8/23/10 between 12:45 p.m. and 1:10 p.m. an interview was held with the Administrator and the Director of Nursing. During this interview both acknowledged that it is the facility's practice and expectation that each staff has evidence of an initial PPD prior to hire and an annual PPD update or evidence of [DIAGNOSES REDACTED] testing and outcome. On 8/24/10 during an interview conducted with the Health Records Executive Assistant, the assistant acknowledged that 6 of 10 health records for new personnel were missing pre-employment evidence of [DIAGNOSES REDACTED] screening and test results. She stated that it is her responsibility for maintaining the accuracy of these files. When asked why the health records were missing the appropriate evidence of screening for [DIAGNOSES REDACTED]. She replied, I failed to follow up with some of the employee health records, but It is my understanding from an RN (Registered Nurse) in charge, and as a matter of fact, from more than one RN, that PPDs (Mantoux) are valid for two years. She also stated that today, however, I became aware that this practice may be controversial amongst the nurses. CDC recommendations for preventing M. [DIAGNOSES REDACTED] transmission in health care settings includes: Testing done at pre-placement, annually, after exposure to a person with infectious [DIAGNOSES REDACTED], for symptoms suggestive of TB, or upon request of the employee. Identification of infected individuals is essential for the control of [DIAGNOSES REDACTED] within the healthcare environment. Screening is to be done on an annual basis in order to (1) identify converters who are at risk for developing disease and (2) monitor the effectiveness of the institutional TB control program. Guidelines for Preventing the Transmission of [DIAGNOSES REDACTED] [DIAGNOSES REDACTED]in Health-Care Settings, 2005 MMWR 2005; 54 (No. RR-17, 1-141) h) On all survey days 8/19/10 through 8/25/10, roaches were observed crawling along corridor floors on both unit A and Unit B, were observed crawling on the walls of the corridors of both units, were seen in resident rooms, were observed crawling along the Nursing stations and were seen crawling on a medication cart and the Medication administration Record during a medication pass observation. Six of six residents confirmed this pest problem during a group meeting held on 8/20/10 at 10:30 A.M. |
2017-01-01 |