cms_WV: 664
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 664 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2018-04-26 | 880 | K | 0 | 1 | FJW311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, observation and infection control policy review, the facility failed to maintain an effective infection control program to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. The facility failed to effectively implement isolation practices for Resident #149. Resident #149, who was diagnosed with [REDACTED].#108) who did not [MEDICAL CONDITION] or [MEDICAL CONDITION] [DIAGNOSES REDACTED].#149 would pick scabs from her open [MEDICAL CONDITION] and flick them about. Resident #108 was unable to understand the need for, and to independently practice hygienic measures such as handwashing. Resident #108 ambulated about the room, touching various environmental objects, and about on the nursing unit at will. This had the potential for Resident #108 to become a vector for Resident #149's infectious disease processes, carrying infective material where other residents, staff, and visitors might have contact. These findings were determined to pose an immediate jeopardy to the health and well-being of others. After consultation with the Office of Health Facility Licensure and Certification (OHFLAC) on 04/25/18 at 12:48 PM and preparation of a written statement regarding the identified deficient practice, the Administrator and Director of Nursing (DoN) were notified of this immediate jeopardy on 04/25/18 at 1:28 PM. The facility provided an acceptable Plan of Correction at 3:45 pm on 04/25/18. After determining the facility had implemented its plan of correction, the immediate jeopardy was abated on 04/25/18 at 3:53 pm After removal of the immediate jeopardy, a deficient practice, with the potential to affect more than a limited number of residents, remained at a scope and severity of E. A nurse administered medications to Resident #44 after dropping them on the medication cart, picking them up with her bare hands, and placing them in a medication cup with other medications. For Resident #99, observations of incontinence care identified breaches of technique that increased the potential for urinary tract infection. Resident Identifiers: #149, #108, #44, and #99. Facility census: 156. Findings included: a) Resident #149 An observation on 04/23/18 at 10:59 AM, noted a sign on a resident's door, See nurse before entering room. Licensed Practical Nurse (LPN) #92 said the resident was in contact isolation because she had [MEDICAL CONDITION] in her nose in the hospital and all the opened sores on her body. She also identified the resident was [MEDICAL CONDITION] positive. It was also noted there was another resident in the room. LPN #92 said that her roommate did not [MEDICAL CONDITION] or [MEDICAL CONDITION]. On 04/23/18 at 11:00 AM, observations found Resident #149 sleeping with her head resting on the side rail. She had multiple opened and scabbed over areas on all exposed skin, some were actively bleeding. Observation on 04/23/18 at 2:28 PM, found Resident #149 awake, sitting on her bed picking at a scabbed area on the top of her head. The curtain between the beds was half open and her roommate was up looking for her TV remote on Resident #149's bedside table. An observation on 04/23/18 at 3:33 PM, the curtain between the beds was pulled less than half way between the beds. During an interview on 04/23/18 at 3:43 PM, the director of nursing (DoN) said the resident (#149) had [MEDICAL CONDITIONS]. The doctor wanted her to be in contact isolation because she picked at her sores. She added that her roommate did not have a history [MEDICAL CONDITION] or [MEDICAL CONDITION], but did not need to be moved. During an interview on 04/25/18 at 9:06 AM, Infection Control Nurse (ICN) #167 said the attending physician said Resident #149 needed to be in contact isolation and a private room. It was brought it the attention of the Administrator, DoN, and the Admission director. They were in on the conversation about moving one of the residents. She said that they try to keep the curtain pulled, because she knows Resident #149 is always picking at her wounds and flicking bits of the scabs about. When informed that the curtain was not always pulled, because the resident's (in isolation) feet and bottom of the bed could be seen. ICN #167 stated that Resident #108 (Resident #149's roommate) kept pulling the curtain back. During an interview on 04/25/18 at 1:29 PM, the DoN said she was not told the doctor had ordered Resident #149 moved to a private room. Resident #149 was admitted on [DATE] and the physician assessed and ordered Contact Isolation [MEDICAL CONDITION] and [MEDICAL CONDITION] on 04/02/18. Although rooms were available, the facility failed to provide an appropriate room for this resident's isolation needs. Resident #149's roommate, Resident #108, independently ambulated throughout her room and the third (3rd) floor of the facility. Resident #108's Brief Interview for Mental Status (BIMS) was 04, indicating severe cognitive impairment. As Resident #108 ambulated, she encountered her roommate, visitors, staff, and other residents. Resident #108 was unable to comprehend the need for proper hand hygiene and need for infection control measures. Review of records revealed nursing notes that stated Resident #149 was picking at her wounds causing bleeding and redirection did not work. Observations noted staff were diligent about wearing a gown, gloves, and a mask with a shield every time they entered Resident #149's room. In the meantime, Resident #108 lived in this room without anything on to protect her. The facility's failure to provide appropriate infection control procedures for a resident diagnosed with [REDACTED]. A determination of immediate jeopardy situation. After consultation with the Office of Health Facility Licensure and Certification (OHFLAC) on 04/25/18 at 12:48 PM and preparation of a written statement regarding the identified deficient practice, the Administrator and Director of Nursing (DoN) were notified of this immediate jeopardy on 04/25/18 at 1:28 PM. The facility provided an acceptable Plan of Correction at 3:45 pm on 04/25/18. After determining the facility had implemented its plan of correction, the immediate jeopardy was abated on 04/25/18 at 3:53 pm The facility's Plan of Correction, received on 04/25/18 at 2:30 PM, included: Resident #149 was moved to a private room and the contact precautions continue. Resident #149 has Capacity and was reeducated by the Infection Preventionist at 2:45 PM, to avoid picking and flicking scabs and asked to inform nurses if areas are itching. DoN will evaluate Resident #108 by 3:00 PM and will discuss findings with the attending physician for any follow up. All residents of the facility have the potential to be affected. The DoN/designees conducted observation of all residents' requiring contact precautions on 04/25/18 at 1:30 PM, and no additional residents were affected. The Nurse Practice Educator (NPE)/designee will begin to re-educate all center staff on 04/25/18 regarding observation of residents in contact isolation do not expose other center residents to blood or bodily fluids with posttest to validate understanding. Staff not available during this timeframe will be provided re-education including post-test by the NPE/designee, upon returning to work. New hires will be provided education and post-test during orientation by the NPE/designee. The Unit Managers (UMS)/designee will conduct observation of residents in contact isolation daily for two weeks across all shifts including weekends, then three times a week for two weeks, then randomly thereafter to ensure that no other center residents are at risk for exposure to blood or bodily fluids of those in contact isolation. Trend identified will be reported to the DoN monthly to the Quality Improvement Committee (QIC) for any additional follow up and/or in-servicing until the issue is resolved and a randomly thereafter as determined by the QIC. After removal of the immediate jeopardy, a deficient practice, with the potential to affect more than a limited number of residents, remained at a scope and severity of E. A nurse administered medications to Resident #44 after dropping them on the medication cart, picking them up with her bare hands, and placing them in a medication cup with other medications. For Resident #99, observations of incontinence care identified breaches of technique that increased the potential for urinary tract infection. b) Resident #44 On 04/24/18 at 9:45 AM, during observation of medication administration, Licensed Practical Nurse (LPN) #40 opened five (5) oral medications for administration to Resident #44. LPN #40 dropped two (2) of the medications, [MEDICATION NAME] and Eliquis, onto the top of the medication cart. She picked up the [MEDICATION NAME] and Eliquis with her bare hands, placed them into the medicine cup along with the resident's other oral medications, and administered the medications to Resident #44. During an interview on 04/24/18 at 9:54 AM, LPN #40 stated she understood how dropping the medications on the top of the medication cart and then handling them with her bare hands could be an infection control issue. On 04/24/18 at 10:00 AM, when the observation was shared with Unit Manager (UM) #17, UM #17 made no comment regarding the matter. c) Resident #99 Observations on 04/24/18 at 11: 39 AM, noted nurse aide (NA) gathering supplies and providing incontinence care for this resident. NA Employee #86 (E#86) placed several clean, folded washcloths directly into the sink basin, shared with two (2) other residents in this room. She ran warm water from the faucet over them until they were completely submerged. E#86 squeezed out the excess water with her gloved hands, then took them to the resident's bed. The resident was incontinent of soft, semi-formed stool which was contained in the perineal and rectal areas and between her legs. [NAME] #86 at first cleaned the resident from the front to the back with one of the washcloths as the resident lay on her left side. She disposed of that washcloth into a clear, plastic bag. When E#86 got to the last washcloth, there was still bowel movement in the vulva/perineal area. She folded over the last, used wash cloth repeatedly, and made three (3) more swipes with that soiled wash cloth to remove the last of the bowel movement from the vulva and perineal area. During an interview with the director of nursing (DON) on 04/25/18 at 6:00 p.m., she said it was against the facility's policy to soak washcloths in a sink basin. She said staff were supposed to use the resident's plastic wash basin for that purpose. The DON also agreed that it was not an acceptable practice to reuse a soiled washcloth to clean the perineal area of an incontinent resident. She said she would do staff education to all staff right away. These findings were shared with the administrator on 04/26/18 at approximately 9:30 a.m. No further information was provided by the facility prior to exit. | 2020-09-01 |