cms_WV: 5395
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5395 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2015-09-02 | 441 | F | 0 | 1 | ZG3O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, policy and procedure review, and infection control surveillance record review; the facility failed to provide a safe, sanitary, and comfortable environment, to help prevent the development and transmission of disease and infection. The infection- control surveillance records were not completed and maintained in their entirety. A bedpan was stored improperly in a bathroom shared by two (2) residents. Nursing staff administered medication to a resident after the medication fell on the top of an unclean medication cart. In addition, two (2) of two (2) medication carts were observed to be dirty with dust and debris. These practices had the potential to affect all residents in the facility. Resident identifiers: #93, #100, #61. Facility census: 53. Findings include: a) Infection control log surveillance records Review of the infection control surveillance records was completed on 08/31/15 at 2:00 p.m. (Surveillance refers to the ongoing, systematic collection, analysis, interpretation, and dissemination of data to identify infections and infection risks to try to reduce morbidity and mortality and to improve resident health status.) Findings were as follows: 1. The (MONTH) (YEAR) infection control monthly line listing contained the names of twelve (12) residents with newly developed infections. None of the twelve residents with newly developed infections were documented as having had resolution of the infections. Nine (9) residents lacked an admitted . Eight (8) residents had no recorded dates of onset of the infections. Nine (9) residents had no room numbers recorded. Eleven (11) infections were not differentiated as to whether they were healthcare acquired or community acquired. Eight (8) cultures did not include the dates of the cultures. All five (5) of the urine cultures lacked the results of the organisms, which grew. In addition, the start dates for eight (8) of the antibiotics prescribed were not documented. 2. Review of the infection control monthly line listings for (MONTH) through (MONTH) found similar results. Many lacked valuable information such as room numbers, admitted s, onset dates of the infections, whether the infections were healthcare acquired or community acquired, the date of the cultures, the results of the cultures, the start dates of treatment, the precaution type, and the date the infections resolved. 3. The Multi-Drug Resistant Organism (MDRO) line listing for Methicillin Resistant Staphylococcus Aureus (MRSA), [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE), Carbapenem-Resistant [MEDICATION NAME] (CRE), Extended-Spectrum Beta Lactamase (ESBL), and Clostridium Difficile (C-Diff) all lacked the admitted fo the affected residents, dates of cultures, and the discharge date s. 4. discharged Resident #93 was listed on the (MONTH) monthly line listing as having Clostridium Difficile (C-Diff), but was not listed on the Multidrug-Resistant Organism (MDRO)[DIAGNOSES REDACTED] line listing. During interview with the infection control nurse, Registered Nurse #13, on 08/31/15 at 2:00 p.m., she said she did not know why she did not complete the infection- control surveillance records more thoroughly. She said the monthly line listing form was changed to a corporate form in (MONTH) (YEAR), and for some reason she was not completing the new form in its entirety. 08/31/15 was her last working day at the facility, and her predecessor would take over the infection control monitoring tomorrow. She agreed that the predecessor would not have enough information from the surveillance records to comprehend the tracking and trending for the most recent months. She agreed that the infection control monthly line listings lacked valuable information such as room numbers, admitted s, onset date of the infections, whether the infections were healthcare or community acquired, the dates of all the cultures, and the culture results. She said she discusses the infection control status with the administrative staff once monthly in a special meeting. She utilized a dry- erase board in these meetings to communicate the types of infection present, and where they were located in the facility. This board as the staff looked for trends or patterns of infections. After the meeting, they erased the board. An interview was completed with the director of nursing (DON) on 08/31/15 at 3:30 p.m. She said she was not present in (MONTH) for the monthly infection control meeting. She agreed that the information on the (MONTH) infection control monthly line listing, and for the MDRO line listings, lacked necessary information to be complete. She said a new infection control nurse was starting on 09/01/15, and would need all that information. She agreed that the new infection control nurse would have inadequate knowledge of the past trending and tracking information based on these surveillance records. At 4:00 p.m. on 08/31/15, the DON provided copies of the (MONTH) through (MONTH) infection control monthly line listings. She acknowledged they were similar in lacking needed information. When informed that Resident #93 was not listed on the Clostridium difficile (C-Diff) Multidrug-Resistant Organism (MDRO) line listing, the DON said she would see that Resident #93's name was added. c) Resident #61 On 08/26/15 at 8:47 a.m., during a medication observation, Licensed Practical Nurse (LPN) #23 attempted to place a tablet into a plastic cup from a blister package, the pill landed on the top of the medication cart. LPN #23 picked up the tablet with bare hands and put it into the plastic medicine cup. LPN #23 then administered the oral medication to Resident #61. During an interview with LPN #23, on 08/26/15 at 8:55 a.m., the LPN stated she did not know what to do when a resident ' s medication was dropped. A review of the facility policy and procedure General Dose Preparation and Medication Administration, on 08/26/15 at 10:27 a.m., revealed the following: 2. Dose Preparation 2.4 Do not touch the medication when opening a bottle or unit dose package. 2.5 If a medication, which is not in a protective container is dropped, discard per policy. During an interview, with the director of nursing (DON), on 08/26/15 at 10:35 a.m., she agreed the oral medication should have been discarded and facility policy and procedure had not been followed by LPN #23. d) Hall 1 & 2 Medication Cart On 08/24/15 at 1:15 p.m., an observation, of Hall 2 medication cart, with Licensed Practical Nurse (LPN) #19 revealed dust and brown debris in each drawer of the medication cart. Hall 2 medication cart, which contained liquid medication, revealed a spilled substance, which had been covered with a paper towel. LPN #19 attempted to remove the paper towel but was not successful. This employee agreed the medication cart was dirty and needed to be cleaned. A concurrent observation of the Hall 1 medication cart, with an LPN #14 revealed dust and brown debris in each drawer of the medication cart. LPN #14 stated she had no idea when the medication cart had been cleaned, and agreed the medication cart needed cleaned. e) On 08/24/15 at 3:00 p.m., an unbagged, unlabeled bed pan was found lying in the bathroom floor of Resident #100. Resident #100 stated the bedpan was for her use. Resident #100 shared the bathroom with another resident. At 3:45 p.m., the director of nursing, stated the bedpan should have been labeled and bagged, and the bedpan would be removed from the room and replaced with a new one, with proper labeling. | 2019-01-01 |