| 3286 |
MAPLES NURSING HOME |
515186 |
1600 BLAND STREET |
BLUEFIELD |
WV |
24701 |
2017-02-09 |
441 |
E |
0 |
1 |
UXFJ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and manual for glucometer care, the facility failed to ensure an effective infection control program designed to prevent the development and/or transmission of disease and infection to the extent possible. Potential for cross-contamination was observed when nursing staff placed reusable patient care supplies directly onto residents' overbed trays without any type of barrier; nursing staff demonstrated improper cleaning and/or disinfection of a resident-shared glucometer after use; nursing staff touched inanimate objects in a resident's semi-private room without first removing disposable latex gloves previously used while cleaning an incontinent resident; nursing staff soaked washcloths in a resident sink prior to use for incontinence care. These practices had the potential to affect more than a limited number of residents on the first floor long hall, but most directly involved Residents #50, #95, #29. Resident identifiers: #50, #95, #29. Facility census: 58. Findings include: a) Resident #50 During observation on 02/07/17 at 7:22 a.m., licensed practical nurse (LPN) #22 placed a glucometer (small machine used to obtain blood glucose tests) directly onto this resident's overbed tray without the use of any type of barrier. After the test was completed, LPN #22 placed the glucometer directly onto the top of the medication cart. This act contaminated the top of the medication cart, which is where a nurse would pour medications for other residents. She then obtained a wipe from a canister and proceeded to wipe off the glucometer before returning the glucometer to the drawer of the medication cart. Observation of the canister found its only active ingredient was a seventy percent (70%) alcohol solution. She did not clean and/or disinfect the top of the medication cart where the glucometer had been placed. During interview with the director of nursing (DON) on 02/08/2017 9:06 a.m., she said there is no need to place the glucometer on any residents' bedside tray. Rather, the nurses are supposed to carry the machine into the resident's room and hold the glucometer in their hands. She said if a nurse laid the glucometer down in the room, a barrier would be needed such as a paper towel. She agreed that when the nurse laid the glucometer on top of the medication cart after it had previously placed directly on the resident's overbed tray, the nurse should have wiped off the top of the medication cart with a disinfectant wipe from the red lidded Med Line Micro Kill canister. The DON said each cart has either packets of sani-wipes with bleach especially made to clean glucometers between patient uses, and/or canisters with red lids of Med Line Micro Kill that are EPA (environmental protection act) registered to disinfect surfaces and glucometers. She said LPN #22 used a sanitizing wipe from the blue lidded canister whose only active ingredient was 70% alcohol. She said those wipes are used only to clean hands. The DON said this canister with 70% alcohol had no EPA registration. The DON provided the facility's glucometer manufacturer's booklet which listed several product brands on pages 43 and 44 which may be used to disinfect the glucometer between patient uses. Both the Med Line Micro Kill and the individual packets of bleach wipes the facility used were included in the list of approved product brands. The blue lidded canister of 70% alcohol wipes was not included in the list of approved product brands to disinfect the glucometer. b) Resident #95 During observation on 02/07/17 at 9:52 a.m., LPN #22 carried a medication box into this resident's room. The box contained an [MEDICATION NAME] hand-held inhaler. LPN #22 placed the box on the resident's beside table with no barrier beneath it. After the resident used the inhaler, LPN #22 placed the inhaler back into the medication box. She then placed the medication box on the countertop of the resident's sink while she washed her hands. Next, she placed the medication box on top of her medication cart while she unlocked the cart. She then returned the medication box which contained the [MEDICATION NAME] inhaler to a drawer of the medication cart. She did not sanitize the medication box after it had been in contact with the resident's overbed tray and sink. She did not sanitize the top of her medication cart after the exposed medication box was placed on it. During an interview with the director of nursing (DON) on 02/08/17 at 9:06 a.m., she said if a nurse placed an inhaler's medication box on an overbed tray, the nurse should place the box on a barrier such as a paper towel. Otherwise, this could potentially cause cross contamination. She agreed that the nurse should also have sanitized/disinfected the top of her medication cart after the exposed medication box had been placed on it. c) Resident #29 On 02/08/17 at 7:25 p.m., nurse aide (NA) #38 performed urinary incontinence care for Resident #29. She placed clean wash cloths directly into the resident's sink beneath the faucets and atop the drain, and ran warm water over the wash cloths. She squirted some red-colored shower wash onto the washcloth, squeezed out the excess water, then placed the wash clothes on the sink's counter top. The NA stripped the resident's bed. She then assisted the resident into the bathroom, and donned a pair of disposable green gloves. The resident held to the grab bar in the bathroom as she removed his wet diaper. When she removed the diaper, the urine odor was quite acrid and pungent with the strong smell of ammonia. She wiped the front of him, then washed his buttocks. She applied a clean diaper, and helped him into a pair of clean sweat pants. While still wearing the same gloves, she touched the bathroom door, went to his closet, touched numerous items of clothing hanging in the closet before selecting a green shirt. She returned to the bathroom with the shirt, removed his old shirt which she said was wet, and helped him into the clean shirt. Still wearing the same gloves, she took hold of the wheelchair and helped him out of the bathroom and wheeled him by his bed. She placed the bed linens, soiled pants and shirt into a clear plastic bag. At this time, she removed her contaminated gloves. She took the bagged clothing and linens out of the room. A minute or so later, NA #38 returned with a canister of Micro Kill Med Line disinfectant wipes, and placed the canister on his overbed table with no barrier beneath it. She wore disposable gloves, and pulled out a couple of sanitizing wipes and began wiping down his mattress. Upon inquiry, she said staff wipe down the mattresses with these wipes every time they change the sheets. She said she obtained this canister from the common use shower room. On 02/09/17 at 9:45 a.m., an interview was completed with the director of nursing (DON). We discussed the details of the incontinence care of the preceding evening. The DON said the aide should not have placed the washcloths in the resident's sink, or placed the wet washcloths on the sink, as these practices are unsanitary. She said the aide should have filled the resident's wash basin with clean water, and should have taken the basin into the bathroom with her. She agreed that organisms from the sink could have led to cross-contamination of the wash cloths. The DON agreed that the NA should have removed her dirty, contaminated gloves before leaving the bathroom and before touching any of the inanimate objects in the room, as this practice could pose the risk for cross-contamination of organisms into the environment. The DON agreed that the NA should not have brought the shower room canister of Micro Kill wipes into the resident's room, nor should she have placed the canister on the resident's table, as these practices could also contribute to cross-contamination of organisms into the resident's environment. |
2020-09-01 |