cms_WV: 35
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 35 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 880 | E | 0 | 1 | 8Y4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and policy review, the facility failed to ensure and maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infection to the extent possible. This was true for observations made in the laundry room regarding an inadequate negative air pressure. This was true for one (1) of one (1) sample residents reviewed for infections (not UTI or Respiratory) who had an exposed open draining wound. This was true of one (1) of three (3) sample residents reviewed for catheter care where a disposable contaminated wipe was placed back in the package with other uncontaminated disposable wipes. This was true for one (1) of four (4) sample residents reviewed for feeding tubes, who had a soiled feeding tube syringe laying out in the open not bagged. This was true for random observations made on two (2) separate occasions for a resident with a Foley catheter; one (1) observation revealed the Foley catheter drainage bag on the floor and one (1) observation revealed the Foley catheter drainage tubing on the floor. This practice had the potential to effect more than a limited number. Resident identifier: R#33, R#68, and R#23. Facility census: 111. Findings included: a) Laundry Room Inspection of the laundry room on 06/06/19 at 09:26 AM with the Environmental Services Director and the Director of Maintenance revealed the laundry room exhaust fan that provided the negative airflow in the dirty laundry room was not working properly. The Director of Maintenance after inspecting the exhaust fan said the exhaust fan was barely pulling air. The Environmental Services Director and the Director of Maintenance both acknowledged there was not adequate negative air flow in the dirty laundry room due to the poor performance of the exhaust fan. Both the Environmental Services Director and the Director of Maintenance confirmed the inadequate negative air flow in the dirty laundry room created an infection control issue. The Director of Maintenance said he would immediately have the fan fixed. b) R#33 - an open draining wound During the initial tour of the annual Long-Term Care Survey Process, on 06/03/19 at 11:15 AM, Surveyor# observed Resident (R#33) with dried crusted drainage around a small open circular wound site located on the resident's upper abdominal right side. This was identified as a concern for further investigation by Surveyor# due to the open wound draining and not being covered with a dressing. Review of records, on 06/10/19 at 11:01 AM, revealed R#33's brief interview for mental status (BIMs) score is fourteen (14) indicating the resident is cognitively intact. Some pertinent [DIAGNOSES REDACTED]. The resident has a history of having abscesses that have needed to be treated with incision and drainage (I&D) procedures. The resident last abscess was on his right side and on 04/04/19, after the drainage tube was removed a new order was given to clean surgical incision to right side with wound cleanser, pat dry, and apply dry dressing every day. Review of the treatment administration record (TAR) revealed daily wound care treatment including a dry dressing was ordered and started on 04/04/19 and on 06/05/19 the wound nurse obtained an order to discontinue treatment due to resident refusing treatment. From the time of the order until the order was discontinued there were sixty-two (62) opportunities to provide daily wound care treatment and it was documented treatment was provided randomly only in the month of April. R#33 received wound care treatment eighteen (18) days due to resident refusing care on the other days, and three (3) times out of the sixty-two (62) opportunities to provide daily wound care treatment there was no documentation either way as to refusal or provision. An interview with the wound nurse, Licensed Practical Nurse (LPN#84), on 06/10/19 at 11:44 AM, revealed LPN#84 said she kept trying to get R#33 to allow her to provide the wound treatment but he always refused. LPN#84 said the resident would let her clean and measure the wound weekly but not provide treatment and place a dry dressing on it daily as it was ordered. This surveyor requested evidence or documentation showing the resident refused wound care treatment, the physician was notified about the refusals of treatment, and R#33 was provided education concerning the importance of wound care and infection control. The facility was unable to provide any documentation or evidence that patient education was provided to the resident or any documentation that showed the physician was notified of the resident's refusals of wound care treatment untill 06/05/19. LPN#84 said she was aware there was still some occasional drainage from the wound site. LPN#84 agreed the physician should have been notified concerning the resident's refusal of daily wound care and dressings and that the open wound was a breech of infection control principals. On 06/10/19 at 01:10 PM, interview with the resident revealed the wound still has some occasional drainage, but not as much as it did. When asked if anyone had explained to him the importance of wound care and applying a dry dressing to cover and catch any drainage the resident stated no one at the facility had talked to him about infections or the proper way to care for the wound. An interview with the Center Nurse Executive (CNE), on 06/10/19 at 2:30 PM, confirmed staff should have notified the physician sooner than 06/05/19, more than forty days after the resident consistently refused wound care treatment. The physician should have been notified when the resident continued refusing wound care treatment, so that the physician could order an alternative treatment if they chose to. The CNE confirmed an open draining wound is an infection control issue. c) R#68 disposable wipes Observations of Licensed Practical Nurse (LPN#84) providing peri-care (washing the genitals and anal area) and catheter care to Resident (R#68), on 06/05/19 at 04:13 PM, revealed a breech in infection control principals. LPN#84 used packaged disposable wipes to provide the peri-care and to clean around the catheter drainage tube inserted in the resident's urethra. When the LPN finished providing peri-care she took her soiled gloved hand that was contaminated from providing peri-care and pushed a clean unused disposable wipe back into the package, thus contaminating the package of disposable wipes. LPN#84 acknowledge this was a breach in infection control principles. d) Resident #23 On 06/05/19 at 10:50 AM observation was made of a 60 milliliter (ml) syringe in Resident's room lying on her bedside table. The syringe was open to air, placed on top of a pile of papers beside a used tissue. The syringe appeared to be soiled with light brown crusty residue inside the syringe and along the tip. Liscensed Practical Nurse (LPN) #110 verified that syringe belonged to Resident #23, and it had been used for bolus tube feedings. LPN #110 agreed the syringe was not stored properly and discarded syringe into the trash. The syringe did not have any information written on it to indicate the time/date it was initiated for use. Review of facility's Enteral Feeding policy revealed instructions to label and date syringe, store in plastic bag or appropriate container, and the syringe can be used for 24 hours. During an interview on 06/05/19 at 12:30 PM the Director of Nursing (DON) agreed the syringe was maintained in an unsanitary manner. The DON stated, The syringe was improperly stored and should have been dated. Moving forward better measures will be taken. e) R68 On 06/03/18 at 2:01 PM during a random opportunity for discovery a catheter bag belonging to R68 was found on the floor under her bed. During an observation on 06/03/19 at 2:03 PM with E114 assistant center nurse executive (ACNE) verified the catheter bag was on the floor and not securely attached to R68's bed. On 06/04/19 at 12:42 PM during a random opportunity for discovery the catheter tubing was dragging on the floor under R68's wheel chair. During an observation on 06/04/19 at 12:44 PM with E27 nursing assistant (NA) verified the drainage tubing was dragging on the floor and not securely attached under R68's wheelchair. A review of the policy for Care of Indwelling Urinary Catheter revised on 02/01/19 states, Secure catheter tubing to keep the drainage bag .off the floor. | 2020-09-01 |