cms_WV: 22
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 22 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 441 | E | 0 | 1 | ELSQ11 | Based on observations, staff interview, and policy review, the facility failed to maintain an effective infection control program to prevent the transmission of disease and infection to the extent possible. Staff failed to utilize proper hand hygiene, failed to utilize personal protective equipment (PPE) when required and/or dispose of PPE properly, and failed to handle medication properly. These practices affected nine (9) of the one hundred sixteen (116) residing in the facility and had the potential to affect additional residents. Facility census: 116. Resident identifiers: #25, #189, #127, #76, #104, #42, #31, #163, and #158. Findings include: a) Residents #25, #189, #127, #76, #104, and #42 During a lunch meal observation, Nurse Aide (NA) #75 touched items in the room of Resident #25, returned to the cart, poured a cup of coffee and placed it on top of the cart. The NA entered the room of Resident #189 who was in contact isolation for clostridium difficile (a highly contagious organism). The NA did not don personal protective equipment (PPE) prior to entering the room. Upon completion of the tray set-up, NA #75 washed her hands for a count of eight (8) seconds. The NA exited the room and poured coffee for Resident #68. Without performing hand hygiene, the NA passed trays to Resident #76 and assisted NA #135 with Resident #104. Upon completion, the NA washed her hands for a count of seven (7) seconds, then passed a tray to Resident #42. b) Resident #25 On 05/17/17 at 6:20 a.m., Nurse Aide (NA) #36 performed care for Resident #25. Upon completion, the NA bagged soiled items. With the same gloves the NA pulled up the resident's covers, picked up the bed remote from the floor and attached the call bell to the bed cover. c) Resident #163 During a wound care observation on 05/18/17 at 10:21 a.m., Nurse Aide (NA) #102 assisted Licensed Practical Nurse (LPN) #72 with wound care. The resident held Resident #163's hands. When the nurse unfastened the resident's brief, she found the resident had an incontinence episode. The NA removed her gloves and without performing hand hygiene exited the room. Upon return, the NA went to the bathroom and donned gloves. Upon completion of care, the NA removed her gloves and exited the room without utilizing hand hygiene. During care, Resident #163 pulled the barrier on the nightstand and a plastic bag with wound care supplies fell to the floor. Upon completion of wound care, LPN #72 removed her gloves and used hand sanitizer. The LPN picked up the plastic bag from the floor which contained gloves and four by four gauze pads. She placed the tube of cream utilized for wound care and the wound care cleanser in the bag. LPN #72 picked up the bag in her right hand and the garbage bag with her left hand and exited the room. She stopped at the treatment cart, placed the bag on top of the cart without first cleansing it, then placed it in the drawer, laying it across the top of other opened bags which contained other residents' supplies, still without cleansing the bag. d) Resident #31 A random observation on 06/01/17 at 4:24 p.m., revealed an isolation cart stationed outside of Resident #31's door. A small trash can, located on the right side of the resident's bed, near the foot of the bed, contained a yellow isolation gown protruding over the top of the garbage can. An isolation mask was located on the floor bedside the bed. Upon request, Licensed Practical Nurse (LPN) #60, completed an observation and said, Not cool. The nurse said the gown should be in a covered container and asked AD #36 to obtain one. The resident was identified as having shingles. e) Housekeeping During a random observation on 05/23/17 from 11:59 a.m. until 12:24 p.m., a bucket of mop water was noted spilled in the hallway at the room of Resident #50. Housekeeping (HSK) #133 and physical therapy assistant (PTA) cleaned the spill using towels to wipe up the contents. They did not wear PPE. Upon completion, HSK #133 wiped her hands down the sides of her uniform pants, as if to further dry them. f) During an interview on 05/30/17 at 2:58 p.m., Registered Nurse (RN) #6, the infection control coordinator, said the facility's policy required staff wash hands for a minimum of twenty (20) seconds. The nurse said the washcloths utilized for peri care should not have been placed in the sink basin, and PPE was required prior to entering the room of the resident in isolation. The RN identified Resident #189's infection as clostridium difficile, which required stringent hand hygiene. The nurse verbalized LPN #72 should have sanitized the bag she picked up from Resident #163's floor, prior to placing it back in the cart, but would have obtained a new bag herself. g) The hand hygiene policy with a revision date of 11/28/16, required staff perform hand hygiene before patient care, before an aseptic (clean) procedure, after any contact with blood or other body fluids even if gloves were worn, after patient care, and after contact with the patient's environment. The policy noted staff might decontaminate with alcohol based rub or wash hands with soap and rub vigorously for 20 seconds, covering all surfaces of hands and fingers. h) Resident #158 During medication administration observations on 05/16/17 at 8:16 a.m. Licensed Practical Nurse (LPN) #132 obtained a box from the drawer of her medication cart which contained Breo Elipta (an inhaler). She carried the box into Resident #158's room, and set the box directly onto the resident's bedside stand. She removed the inhaler and handed it to the resident to use. After the resident finished with the inhaler, LPN #132 placed the inhaler back into its box. She then placed the box directly onto the countertop of the resident's sink while she washed her hands. She then placed the box back into the drawer of the medication cart. During an interview with the director of nursing on 05/17/16 at 5:15 p.m., the risk of possibly transmitting pathogens by not maintaining a barrier between clean objects (medication box) and resident furnishings during the medication pass was discussed. She agreed, and said she would educate the nurse. | 2020-09-01 |