cms_WV: 10087
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10087 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2010-03-04 | 441 | F | 0 | 1 | FFCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on a review of the facility's hand hygiene procedure and staff interview, the facility failed to establish handwashing guidelines in accordance with current professional standards of practice as recommended by the Centers for Disease Control and Prevention (CDC). This had the potential to affect all residents. Facility census: 122. Findings include: a) Review of the facility's hand hygiene procedure found, at Step 6, "Rub hand together vigorously for 10-15 seconds, generating fraction on all surfaces of the hands and fingers." The policy was reviewed with the director of nursing on 03/03/10 at 12:00 p.m., at which time it was discussed that current CDC guidelines for hand washing indicate hands should be rubbed together for 15-20 seconds. --- Part II -- Based on record review, staff interview, and policy review, the facility failed to follow its own policy on [DIAGNOSES REDACTED] (TB) screening to assure all newly admitted residents were tested and found to be free of this communicable disease. This was evident for one (1) of three (3) residents' closed records. Resident identifier: #114. Facility census: 112. Findings include: a) Resident #114 Review of the facility's policy on TB screening (dated November 2008) revealed all new residents must have a 2-step Mantoux Purified Protein Derivative (PPD) on admission. The first step is to be completed within seven (7) days of admission or according State / Federal regulation, and the second step is to be completed within seven (7) to twenty-one (21) days after a negative result from the first step or according to State / Federal regulation, always following the more strict requirement. The administration and results are then to be documented on the TB Screening Record in millimeters (mm). Review of Resident #114's medical record, on 03/04/10, revealed the Step 1 PPD was administered on 09/21/09 in the left forearm to be read on 09/23/09; however, on 09/23/09, the results of the test were not read as evidenced by a blank space where the area of "mm of induration" was supposed to have been recorded and by a blank space where the nurse was supposed to have initialed as having read the results. Additionally, the Step 2 PPD was scheduled to be given on 10/05/09 and read on 10/07/09, but spaces were left blank regarding the manufacturer, lot number, dose, nurse's initials when the PPD was given, and "mm of induration" and nurse's initials when read, signifying that a second PPD was not given. Interview with a nurse (Employee #25), on 03/04/10 at approximately 10:00 a.m., revealed the PPD tests were also recorded on the medication administration record (MAR). Review of the resident's September 2009 MAR for 09/21/10 found a typed notation to "check PPD on 09/23/09", but the space to record the results on 09/23/09 was left blank. Employee #25 agreed there was no documentation of test results for the Step 1 PPD. Review of the October 2009 MAR revealed a PPD was initialed as having been given on 10/05/09, and there was a minus (-) sign on 10/07/09 with a nurse's initials signifying a negative PPD result. The 10/07/09 PPD test result was not recorded on the TB Screening Record, and there was no evidence of a second step having been completed seven (7) to twenty-one (21) days after the only PPD on record. . | 2015-07-01 |