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Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 4, 2019
Corrected date: July 31, 2019
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during the recertification survey, the facility did not ensure it established and maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for: 8 of 8 residents observed during a medication pass (Residents #4, 5, 11, 31, 150, 166, 168, and 212); 2 of 2 residents (Residents #53 and 222) reviewed for droplet precautions; and 1 of 2 washing machines reviewed. Specifically, a nurse did not complete hand hygiene between Residents #4, 5, 11, 31, 150, 166, 168, and 212 during a medication pass; multiple staff did not use personal protective equipment (PPE, mask, gloves, gown worn to prevent the spread of infection) when caring for Residents #53 and 222 on droplet precautions for influenza; and 1 of 2 washing machines was not maintained per manufacturer guidelines. Finding Include: The 1/11/11 policy, Droplet Isolation Precautions, documented staff should wash hands for a minimum of 20 seconds between residents, wear a mask when within 6 feet of the resident, and if cohorting residents (semi-private room sharing) they should be 6 feet apart, and the privacy curtain should be pulled at all times. The 4/5/17 policy, Hand Hygiene, documented hand hygiene should be completed either with soap and water or alcohol-based hand rub (ABHR) before and after resident contact, and after removing gloves. The 3/21/19 policy, Infection Prevention and Control Program, documented standard precautions applies to all residents and includes hand hygiene, PPE use depending on the care to be provided, and shared equipment is to be cleaned and disinfected between residents. Hand Hygiene: During a medication pass on 5/31/19, LPN #9 did not perform hand hygiene: -from 9:34 AM- 9:47 AM before and after administering medications to Residents #11, 212 and 168; -at 9:55 AM before preparing and administering Resident #150's medications, in between glove changes when applying a medicated cream on the resident, administering eye drops, and then applying lotion and wraps to the resident's legs; -at 10:12 AM, before or after administering medications to Resident #4; -at 10:15 AM, after transporting Residents #31 and 5 in their wheelchairs from the hall to their shared room (the room was labeled as being on contact isolation), and in-between glove changes when medications were administered to both residents in the room; and - at 10:41 upon exiting Resident #31 and 5's room (contact precautions) and preparing and administering medications for Resident #166. The LPN was observed touching the trash container in the room. She did not perform hand hygiene before applying new gloves and after assisting the resident after he spit out some of his nutritional supplement. During an interview on 6/04/19 at 11:46 AM, LPN #9 stated hand hygiene should be completed between each resident and after every treatment. She stated she did not believe she completed hand hygiene between residents during the medication pass observed and she should have. During an interview on 6/04/19 at 11:56 AM, the Infection Control Nurse (ICN) stated nurses should be completing hand hygiene before and after each resident contact. During an interview on 6/04/19 01:16 PM Assistant Unit Manager LPN #10, stated staff should complete hand hygiene before and after care for each resident. Hand sanitizer should be used after glove changes during a dressing change. She expected staff to wash with soap and water after caring for 3 residents and to use hand sanitizer between each one. Staff should be following the instructions on the isolation signs any time the room was entered. Personal Protective Equipment Use: Resident #222 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. The 4/16/19 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment. A nursing progress note dated 5/26/19 at 9:50 PM documented Resident #222 was diagnosed with [REDACTED]. Resident #53 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. A nursing progress note dated 5/29/19 at 11:49 AM documented Resident #53 was tested for flu, results were pending, and the resident was placed on droplet precautions. On 5/30/19 at 10:34 AM a nursing progress note documented the resident tested positive for influenza Type A and continued on droplet precautions. The following observations were made on 5/30/19: - At 10:25 AM, a sign was posted outside Resident #222's room stating droplet precautions were in effect and a cart with personal protection equipment (PPE, gloves, mask, gowns) was located under the sign. - At 10:27 AM, certified nurse aide (CNA) #7 entered Resident #222's room with gloves on and did not put a surgical mask or gown on. She exited the room with gloves on. - At 10:30 AM, CNA #7 re-entered Resident #222's room with gloves on and no other PPE. - At 10:34 AM, Resident #53's rooms had a sign posted outside the room indicating droplet precautions were in effect and a cart containing PPE was located under the sign. - At 12:29 PM, CNA #7 entered Resident #53's room with a lunch tray in her hands. She did not don PPE, remained in the room as she set up the tray for the resident, cut up the resident's food, and exited the room without performing hand hygiene. - At 12:30 PM, CNA #7 entered Resident 222's room without PPE, delivered a lunch tray and exited the room without performing hand hygiene and returned to the dining room where she approached residents at a table. - At 12:36 PM, LPN #15 entered Resident #53's room without PPE and did not perform hand hygiene. LPN #15 offered the resident assistance with her drinks and exited the room with the tray. She set the tray down on a cart in the dining/serving area, opened the refrigerator to obtain an item, and then waited near the food service line. The LPN did not perform hand hygiene. - At 12:59 PM, CNA #6 entered Resident #53's room without performing hand hygiene or donning PPE. The resident was coughing, CNA#6 assisted the resident and exited the room without performing hand hygiene. CNA #6 then entered Resident #222's room and exited without PPE or hand hygiene and entered another resident room and exited. The CNA then went to the dining/serving area, obtained a new tray without performing hand hygiene and entered another resident room without donning PPE or performing hand hygiene. She sat next to the resident's bed and assisted her with the meal. On 5/31/19 the following observations were made: - At 9:10 AM, an unidentified CNA delivered a meal tray to Resident #222's room without donning PPE or performing hand hygiene upon entry and exit. The CNA returned to the dining/serving area and obtained another breakfast tray without performing hand hygiene. On 5/30/19 at 12:27 PM, Assistant Unit Manager, licensed practical nurse (LPN) #3 stated in an interview Residents #53 and 222 were positive for the [MEDICAL CONDITION] and anyone entering the room should don PPE including a mask, gown, and gloves and perform hand hygiene before entering and exiting. CNA #7 was interviewed on 6/4/19 at 11:25 AM and stated droplet precautions included the use of a yellow gown, gloves, mask, and performing hand hygiene before entering and when exiting the room. She stated she would use the PPE when providing direct care to the resident and would not use PPE for dropping off or retrieving meal trays. She stated she thought the PPE was only for when she was hands on. She stated when delivering or retrieving meal trays, there was no place to set the tray to don/doff PPE or perform hand hygiene, so she would try and do it once she returned to the dining room. During an interview on 6/4/19 at 11:41 AM, Assistant Unit Manager LPN #3 stated all staff were expected to follow proper isolation procedures as detailed on the signs outside the rooms. For droplet precautions, masks, gowns, and gloves should be donned prior to entering the room along with completing hand hygiene. For meal delivery and tray set up hand hygiene and a mask upon entering the room were required. Hand hygiene should be performed upon exiting the room. If staff remained in the room to assist a resident with their meal, he expected staff to don the gown, gloves, and mask while in the room. He stated Residents #53 and 222 were positive for influenza and were on droplet precautions 5/30 and 5/31/19. He stated use of the mask, gloves, and hand hygiene were important to prevent the spread of [MEDICAL CONDITION]. During an interview on 6/4/19 at 12:00 PM, CNA #6 stated the procedure for droplet precautions was to use the gown, gloves and mask. There was a sign outside the room if someone did not know. She stated she was confused about how to handle meals, as there was no place to set a tray down to wash her hands or don PPE. She stated she did not have any PPE and did not perform hand hygiene when assisting Residents #53 and 221 and did not think she performed hand hygiene in between residents when clearing trays. She stated she should have washed her hands in the dining/lounge area after putting the used trays away, but she did not do so because she was so busy with meal service. Laundry Services: During an observation on 6/3/19 at 10:21 AM, the laundry room had two washing machines. During record review on 6/3/19 at 2:19 PM, a front load washer-extractor was not maintained as per user manual. The manufacturer instructions for front load washer #1 documented the following: Monthly: - lubricate bearings; - determine of V-belts require replacement or adjustment; - remove back panel and check for leaks; - unlock the hinged lid and check supply dispenser hoses and connections; - clean inlet hose filter screens; - tighten motor mounting bolt locknuts and bearing bold locknuts, if necessary; - use compressed air to clean lint from motor; - clean interior of washer extractor, both basket and shell; and - use compressed air to clean moisture and dust from all electrical components. Quarterly: - tighten door hinges and fasteners, if necessary; - tighten anchor bolts, if necessary; - verify that the drain motor shield is in place and secure; - check all painted surfaces for bare metal; and - clean steam filter, if applicable. The other washer did not have any specific maintenance requirements. During an interview on 6/3/19 at 2:19 PM, the Director of Environmental Services stated the monthly and quarterly maintenance for the washer was done but not documented. Items on the list were fixed as needed/requested. 10 NYCRR 415.19(b)(2)(4)(c) | Plan of Correction: ApprovedJuly 17, 2019 TAG: 880 (Infection Control) I. Action for Cited Issue(s): Residents # 4, 5, 11, 31, 150, 166, 168, 212, 53, 222 The Director of Nursing (DON) Services and Infection Control Preventionist (ICP) reviewed the 24hour report for the following Residents (# 4, 5, 11, 31, 150, 166, 168, 212, 53 and 222) and concluded the residents did not experience any new or a deterioration in infection control symptoms. (6/19/19) The nursing staff on all units were re-educated by the Staff Educator and Associate Director of Nursing (ADON) regarding the need for compliance with facility policies on hand hygiene, precautions, and use of personal protective equipment (PPE). (6/18/19 & on-going) The Director of Nursing (DON) re-educated LPN#9 on the following expectations: appropriate hand hygiene must be implemented 1) before applying new gloves; 2) after touching trash; 3) anytime there is contact with body fluids; 4) before and after administering medication; 5) in between glove changes when applying medications or treatments; and 6) after transporting residents in their wheelchairs to their room which required contact precautions. (6/18/19) The ADON will re-educate C.N.A.#7 and CNA #6 on the following expectations: 1) appropriate PPE must be implemented upon entering a room with precautions per policy and precaution signage; and 2) upon exiting a resident room, hand hygiene must be performed upon exiting the room per policy. It was also clarified that compliance with appropriate PPE is consistently required upon entering resident rooms who are on precautions, regardless of the purpose for entering the room, eg., whether for direct care or for meal service. (6/26/19) The ADON re-educated LPN#15 on the following expectations: 1) appropriate PPE must be implemented upon entering a room with precautions per policy and precaution signage; and 2) upon exiting a resident room, hand hygiene must be performed per policy. (6/26/19) The DON re-educated the Assistant Unit Manager LPN #3 on the expectation that staff members not providing hands on care and/or who are not at risk of exposure to bodily fluids are not required to don a gown, but rather gloves for contact precautions or mask and gloves for droplet precautions prior to entering the room along with demonstrating proper hand hygiene. (6/26/19) II. Actions Taken to Identify Other Potentially Affected Areas: Unit Nurse Managers and Assistant Unit Managers will observe medication and treatment administration on an identified day to verify compliance with proper hand hygiene per policy including before and after administering medication, in between glove changes when applying medications or treatments, and between residents. Any issues identified will receive prompt follow up with corrective action taken (as indicated). (7/5/19) Unit Nurse Managers and the ICP will observe the LPNs and CNAs during the provision of care during an identified period of time to verify the following: 1) appropriate use of PPE per policy upon entering and exiting resident rooms who are identified with precautions (including for meal service); and 2) compliance with required hand hygiene per policy, including upon exiting a resident room and after contact with trash. Any issues identified will receive prompt follow up with corrective action taken (as indicated). (7/5/19) III. Measures and Systems: The Vice President for the Nursing Facility (VPNF), DON and (ICP) reviewed the following policies on 6/17/19 and identified the following: ?Çó Hand Hygiene Policy (#40-2000-20). The policy effectively outlines how to perform hand hygiene and when it is required, eg., before and after the provision of care, contact with body fluids, after removing gloves, etc. ?Çó Standard Precaution Policy (#40-2000-16). The policy effectively outlines the selection and use of PPE along with the hand hygiene requirement. ?Çó Contact Isolation Precaution Policy (#40-2000-14) and Droplet Isolation Policy (#40-2000-15). The policies effectively outline the selection and use of PPE along with the hand hygiene requirement. It was determined these policies will be incorporated into one new policy on Transmission Based Precautions which will be enhanced to include how room meal trays are managed. ?Çó Infection Prevention & Control Program (#40-2000-25). The policy effectively outlines the selection and use of PPE along with the hand hygiene requirement. ?Çó Medication Administration Policy (#40-1650-09). The policy outlines the hand hygiene requirement. The VPNF, DON and ICP verified the following systems are in place to help support compliance with infection control standards including appropriate use of PPE and hand hygiene: 1) The Nursing Pharmacy Consultant performs periodic medication pass audits which include hand hygiene; 2) The ICP conducts (weekly) infection control rounds on the nursing units with Unit Manager / Assistant Unit Manager; 3) Infection control as it applies to PPE and hand hygiene is integrated into the facility?ÇÖs orientation and annual in-service training; and 4) The ICP monitors trends with infections on a daily and monthly basis. (6/17/2019) The VPNF, DON and ICP will complete the above-stated policy development. (7/17/2019) Staff Education, or designee(s), will re-educate the Nursing Staff (including agency staff) and Dining/Nutrition staff (as applicable) on the above-stated policies with emphasis on the content points identified. (7/31/2019) IV. Monitoring: 7/31/2019 & On-going: The DON, or designee, will audit hand hygiene and proper PPE use on the nursing units during the provision of care, meal service and medication and treatment administration to verify compliance per policy for the above-stated items. Auditing will commence in (MONTH) with the outcomes reported by the DON, or designee, to the (MONTH) 2019 nursing facility Quality Assurance & Improvement (QA & I) Committee. Continued frequency of audits will be determined by the QA & I Committee based on audit results. Quality Assurance outcomes will be tracked by the Vice President of Quality Management and reported to the Quality Assurance & Improvement Committee of the Board of Trustees, whose Chairperson or designee reports to the full Board of Trustees at the quarterly Board Meeting. The DON has the accountability to ensure compliance. The Date Certain for compliance is 7/31/2019 TAG: F880 (Laundry Services) I. Action for Cited Issue(s): The VP for the Nursing Facility (VPNF) re-educated the Director of Support Services (DSS) on expectation to ensure all facility equipment used to launder facility and resident items are maintained on a preventative maintenance schedule which aligns with the manufacturer?ÇÖs guidelines to adequately satisfy the infection control standards. In addition, the preventative maintenance performed must be adequately documented to substantiate the facility is in compliance with the manufacturer?ÇÖs specifications on preventative maintenance. (6/10/2019) The DSS re-educated the Maintenance Team on the on the above content points. (6/19/2019) The DSS / designee executed the following to ensure compliance with the facility?ÇÖs identified washing machine: ?Çó Reviewed the manufacturer?ÇÖs specifications and identified the required preventative maintenance scope of work. (6/12/2019) ?Çó Performed the required scope of work on the identified equipment (6/19/2019) ?Çó Documented the preventative maintenance performed (6/19/2019) ?Çó No additional service or repairs were identified during the preventative maintenance work (6/19/2019) ?Çó The DSS verified the work was completed per standards (6/19/2019) II. Actions Taken to Identify Other Potentially Similar Issues: The DSS / designee identified the facility?ÇÖs additional laundry equipment (washers and dryers) and executed the following to ensure compliance with the preventative maintenance standards: ?Çó Reviewed the manufacturer?ÇÖs specifications and identified the required preventative maintenance scope of work. (6/17/2019) ?Çó Performed the required scope of work on the identified equipment (6/19/2019) ?Çó Documented the preventative maintenance performed (6/19/2019) ?Çó No additional service or repairs were identified during the preventative maintenance work (6/19/2019) ?Çó The DSS verified the work was completed per standards (6/19/2019) III. Measures and Systems: The DSS, VPNF and Fire, Safety, & Security Coordinator (FSSC) reviewed the Physical Plant and Equipment Management Policy (30- -01) on 6/12/19 and concluded that it could be enhanced to include the following: ?Çó Laundry equipment (washers and dryers) are required to be maintained on a preventative maintenance schedule per the manufacturer?ÇÖs guidelines with supporting documentation to ensure compliance with infection control standards. ?Çó An updated Laundry Equipment Preventative Maintenance Log will be developed that outlines the scope of work required per piece of equipment and the targeted frequency. ?Çó The preventative maintenance tasks must be reflected on the Maintenance Department?ÇÖs activity calendar and their QA dashboard. The DSS and VPNF will complete the above-stated Policy and Log enhancements and updates to the QA Dashboard and the Maintenance Department?ÇÖs monthly activity calendar. (7/17/2019) The DSS will in-service the Maintenance and Laundry Team on the above-stated updated policy. (7/31/2019) IV. Monitoring: 7/31/2019 & On-going: The Director of Support Services, or designee, will report on the outcomes of the on-going maintenance quality control inspections to verify compliance with the facility?ÇÖs updated policy on prevention maintenance of laundry machines to ensure the infection control standards as required per regulation. Inspections will commence in (MONTH) with the outcomes reported by the DSS, or designee, to the (MONTH) 2019 nursing facility Quality Assurance & Improvement (QA & I) Committee. Continued frequency of audits will be determined by the QA & I Committee based on audit results. Quality Assurance outcomes will be tracked by the Vice President of Quality Management and reported to the Quality Assurance & Improvement Committee of the Board of Trustees, whose Chairperson or designee reports to the full Board of Trustees at the quarterly Board Meeting. The Director Support Services has the accountability to ensure compliance. The Date Certain for compliance is 7/31/2019. |