cms_WV: 11379
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11379 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2010-12-09 | 520 | F | 3ZOF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of the facility's infection control policies and procedures related to scabies, review of other facility documentation, and staff interview, the facility's quality assessment and assurance (QAA) committee failed to implement appropriate plans of action to prevent the spread and re-infestation of scabies when a resident was diagnosed with [REDACTED]. The facility was aware of potential quality deficiencies associated with the implementation of policies and procedures to prevent the spread of scabies, as the facility was previously cited for non-compliance related to the facility's failure to respond appropriately to an outbreak of scabies during a complaint investigation completed on 06/16/10. These practices had the potential to result in more than minimal harm to all residents. Facility census: 115. Findings include: a) Observations, during a tour of the facility beginning on 11/15/10 at 7:15 p.m., found several open clear plastic bags in residents' rooms throughout the facility. In an interview on 11/15/10 at 7:15 p.m., a nursing assistant (Employee #145) confirmed the facility had an outbreak of scabies. Employee #145 stated, "We are to leave all the residents' personal items that cannot be washed in a sealed plastic bag for 7 days. November 19th will be the last day." The bags, when examined, were not labeled to instruct staff, residents, and/or visitors to not open them until a certain date had come to pass, nor was there any way to determine whether the items in the bags had remained contained for a period of at least seven (7) days. The nursing assistants, when questioned about these bags, confirmed they had to remain sealed until seven (7) days after they were originally bagged. - According to the facility's policy titled "4.12 Scabies" (last revised on 02/01/10), the following process was to be implemented: "5 - Implement procedures to eliminate infestation and prevent transmission to others. "5.1 - Use Contact Precautions until 24 hours after treatment is administered. ... "5.2 - Simultaneously treat all persons affected. All symptomatic health care workers, visitors, volunteers, and their contacts should be treated. Asymptomatic family members, roommate, and anyone who has had skin to skin contact with the patient should also be treated. "5.2.1. - Develop a contact list to identify all persons who had direct physical contact with the patient and their contacts. ... "5.4 - Place unwashable items (shoes, slippers, pillows, stuffed animals, etc.) in a plastic bag and keep sealed for seven days. "5.4.1 - Label bag 'Do Not Open until ____ (date).'" - Subsequent observations during tour of the facility with the administrator (Employee #68) on 11/15/10 found the following: - At 7:45 p.m., Resident #36 was rummaging through a clear plastic bag on the floor of her room. There was no label attached to the bag to identify that the bag should not be opened until a specific date. Resident #36 had over ten (10) clear plastic bags full of unwashable items in the corner of her room with no labels. - At 7:55 p.m., Resident #13's room was noted to have a clear plastic bag that was too full and could not be sealed. The bag was not labeled to identify when it was safe to open. - A follow-up tour with the administrator on 11/16/10 revealed the following: - At 10:00 a.m., Resident #98 had a clear plastic bag in her room containing stuffed animals and flower arrangements. The bag had no label identifying when it was safe to open. The administrator stated, "I swear everything was labeled." At 10:15 a.m., Resident #40 had a clear plastic bag full of personal items stuffed under her bed. The bag was torn, and loose items were out on the floor. The bag, which was also not labeled, was identified to the administrator. - The action item of bagging all unwashable personal items for a period of seven (7) days was not fully implemented as required by facility policy. -- b) Interview with the director of nursing (DON), on 11/17/10 at 10:15 a.m., revealed the facility recently had an outbreak of scabies among both staff and residents. When asked how many individuals were affected, she reported one (1) resident and one (1) employee were actually diagnosed with [REDACTED]. Review of the infection control monthly line listing revealed three (3) residents who were identified with a rash. Review of facility documentation revealed the administrator, on 11/5/10 at 1:30 p.m., notified the county health department of a confirmed case of scabies. (Resident #103 was sent to a dermatologist on 11/01/10, where he was biopsied, and he was confirmed to have scabies at 11:27 a.m. on 11/04/10.) At first, the facility treated only seventeen (17) residents on one (1) unit. On 11/09/10 at approximately 10:45 a.m., the facility again contacted the local health department (LHD) to report they identified another resident with a rash on another unit. According to facility's "Scabies Case / Contact Line-Listing Form: Patients:" submitted to the LHD on 11/09/10, the facility reported having five (5) residents with a rash (#103, #92, #86, #5, and #116); these cases were identified between 11/01/10 and 11/08/10. According to the facility's "Scabies Cleaning Timeline - 11/5/10", the following timeline of actions was to be implemented: 11/05/10: - Contact families for 100 hall - Bag all clothes and wash clothes for 100 Hall - Bag all non-washable items for seven (7) days for 100 Hall - Cream ([MEDICATION NAME]) patients on 100 hall 11/06/10: - Shower the 100 Hall residents - Clean 100 hall rooms 11/09/10: - Contact the remaining of North families - Bag all clothes and wash clothes for North - Bag all non-washable items for 7 days for North - Cream patients on North 11/10/10: - Shower the remaining of North Residents - Clean the remaining of the North rooms - Contact Families on TCU - Bag all clothes and wash clothes for TCU - Cream patients on TCU - Vacuum Floors 11/11/10: - Give the Med Ivermectin for TCU and North - Clean the TCU rooms - Rewash 100 Hall clothes - Contact Families on South - Bag all clothes and wash clothes for South - Bag all non-washable items for 7 days for South - Vacuum floors 11/12/10: - Give the Med Ivermectin for South residents - Clean the South rooms - Clean all Dining Room Chairs and Dining Rooms - Vacuum Floors - The action item of simultaneously treating all persons affected (including all symptomatic and asymptomatic health care workers, visitors, volunteers, family members, roommate, and anyone who had skin-to-skin contact with the resident) when the first case of scabies was confirmed was not implemented as required by facility policy. -- c) In a written statement provided by the DON on 11/17/10, the facility held their last quarterly QAA committee meeting on 07/02/10. During that meeting, the committee discussed the procedures to be taken in a scabies outbreak. One (1) item listed on the written statement was that the facility would bag all items in resident rooms, label, and date them for when the bags are to be opened. The facility did not list a monitoring action to ensure that all procedures were implemented during a scabies outbreak. | 2014-04-01 |