cms_WV: 84
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 84 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 880 | F | 0 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy and procedure review, the facility failed to maintain an effective infection control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection. Observation of pressure ulcer dressing changes revealed no use of a barrier, soiled dressing placed on an overbed table next to water pitcher and drinking glasses and failure to change gloves when going from the buttocks area to the residents back. During medication administration, residents medication was placed on the resident's overbed table without any type of barrier. In addition, the laundry room lacked separation between the clean and soiled areas to prevent cross contamination and failed to change contaminated gloves while changing a resident's tube feeding. Three (3) breakfast trays were found in the Nutrition room [ROOM NUMBER] hall after the lunch meal had been returned to the kitchen. One of the breakfast tray was from a resident who was on isolation precautions. This practice has the potential to affect more than a limited number of residents. Resident identifiers: #116, #76, #115, #101, #98. Facility census: 140. Findings included: a) Resident #116 On 07/30/19 at 10:22 AM observation of pressure ulcers dressing change with Licensed Practical Nurse (LPN) #1 revealed clean dressings were placed on the residents bed. b) Resident #76 On 07/31/19 at 10:52 AM observation of pressure ulcer dressing change by LPN #1 revealed there was no barrier placed on the overbed table or was the overbed bed cleaned prior to opening pressure ulcer dressings. The soiled dressing was placed on the overbed table next to the Resident #76 water pitcher and drinking cups. In addition, obtained marking pen from pocket, dated the dressing, and placed the pen back into pocket with contaminated gloves. c) Resident #115 Observation of a pressure ulcer dressing on 07/31/19 at 11:37 AM with LPN #1 revealed the coccyx area was cleaned and then the pressure ulcer on the back was cleaned without changing contaminated gloves. In addition, no barrier was used on the overbed table nor was a trash can and/or plastic bag used to dispose of soiled dressings and/or 4x4 (gauze pad) used to clean the pressure ulcers. On 08/05/19 at 12:45 PM a review of the facility policy titled Dressings, Dry/Clean found the following: 1. Clean bedside stand. Establish a clean field. 2. Place the clean equipment on the clean field. 3. Tape a biohazard or plastic bag on the bedside stand or use a waste basket below clean field. 7. Pull glove over dressing and discard into plastic or biohazard bag. 15. Cleanse the . Clean from the least contaminated area to the most contaminated area. 18. Discard disposable items into the designated container. The Director of Nursing (DON) and the Assistant DON - Infection Control Nurse (ICN) agreed the policy and procedure were not followed during the Pressure Ulcer dressing changes on the 08/05/19 at 12:45 PM. d) 300 Hall On 07/29/19 at 12:33 PM the three-hundred (300) hall observation of the three-hundred (300) with one breakfast tray (already used by resident), placed on the counter top. Licensed nurse (LPN) #143 explained the resident takes longer to eat and the tray would be sent to the kitchen with lunch trays, and agreed the tray should have been sent to the kitchen upon the resident completing the breakfast meal. Again on 07/30/19 at 12:45 PM the (300) hall nutrition room had three (3) breakfast trays (already used by resident), placed on the counter top with one of these trays belonging to a resident in isolation for, extended spectrum beta-lactamases (ESBL) infection in the urine. Licensed nurse #8 explained the kitchen should have been called to pick up the trays. e) Laundry room On 07/30/19 at 10:20 AM, an observation of the laundry area with Housekeeper #123 revealed one room with washing machines on one wall, dryers along the opposite wall and a large cart of bagged soiled linen sitting between the rows of machines. During this observation, Housekeeper #123 confirmed there was no separation between the clean and soiled laundry. The Infection Control Nurse/Assistant Director of Nursing confirmed the laundry room lacked separation to prevent cross contamination during an interview on 07/30/19 at 11:00 AM. f) Resident #98 - Tube feeding On 07/30/19 at 1:10 PM, Licensed Practical Nurse (LPN) #140, donned clean gloves and began preparing Resident (R) #98's tube feeding. LPN #140, filled two (2) feeding bags, one with tap water and the other with [MEDICATION NAME] 1.5. LPN #140 picked up the trash can with her gloved right hand, placed the can by the bedside, primed the feeding pump and feeding tubing and attached the feeding to R#98's gastric tube without changing her right glove. During an interview immediately following this observation. LPN #140 confirmed she contaminated her glove when she picked up the trash can and should have immediately changed it before proceeding. g) Resident #101 - Medication Administration An observation of medication administration, on 08/05/19 at 8:17 AM, revealed Registered Nurse (RN) #5 took pills from the medication cup and poured them onto Resident #101's bedside table without any kind of barrier or cleansing of the surface first. An interview with RN #5, on 08/05/19 at 8:19 AM revealed she stated I should have put down a barrier on the table. It is the only way he will take his pills. | 2020-09-01 |