Health inspection·May 24, 2023

REGULATION VIOLATION: 72321. Nursing Service -Patients with Infectious Diseases. (b) The facility shall adopt, observe, and implement written infection control policies and procedures. On April 4, 2023, at 7:30 AM, an unannounced visit was conducted at the facility for a recertification survey. The facility failed to ensure their infection control program was followed placing patients at risk for cross-contamination of infectious pathogens when: 1. Three dialysis caregivers (Caregiver 1, 2 and 3) from [Name of dialysis center] accessed the Central Venous Catheter (CVC, a flexible thin tube that is inserted to the vein to the large artery of the heart used for hemodialysis, (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys no longer work, a life sustaining procedure) and practiced poor infection control for two of three (Patients 216, and 220) of 3 hemodialysis sampled patients. This deficient practice had the potential to promote development and spread of communicable diseases and infections to Patient 216 and Patient 220, who are vulnerable and immunocompromised (when one's immune system's defenses are low, affecting its ability to fight off infections and diseases) residents who are receiving hemodialysis. 2. One Licensed Vocational Nurse (LVN 1) entered a transmission-based precaution room (a separate room that keep residents with certain medical conditions or infections separate from other people while they receive medical care) with contact precautions (require anyone entering the room to wear gown and gloves) without a gown for one of three residents (Patient 30) in a shared room. This failure had the potential to cause cross-contamination of infectious pathogens (bacteria and microorganisms transferred unintentionally from one object to another) within the facility. 3. One Licensed Vocational Nurse (LVN 1) did not clean and disinfect a glucometer (medical device used to measure glucose in the blood) for two of three residents (Patient 416 and Patient 417) in a shared room and stated she cleaned and disinfected the glucometer only after an isolation room and at the end of her shift. This failure had the potential to result in blood-borne infections (viruses that are carried in the blood). 4. One Certified Nursing Assistant (CNA 1) entered the contact isolation room for Patient 30 without hand hygiene or personal protective equipment (PPE specialized clothing or equipment worn to protect against infectious materials) and exited the room without hand hygiene. This failure had the potential to cause cross-contamination of infectious pathogens from one resident (Patient 30) to others in the facility. 5. The Housekeeping Aide (HA 1) collected trash from one room, Room 219, to another room, Room 218, without observing hand hygiene, then walked along the hallway wearing the same used gloves going to another room. This failure had the potential to spread contaminants present from the contents of the trash bins into the surrounding areas of the facility. 6. Two trash bins in two resident rooms (Rooms 218 and isolation room 207 a room on contact isolation (precaution used when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient has handled) were overflowing with used Personal Protective Equipment (PPE), causing the trash bin lid to remain open. This failure had the potential to spread infectious organisms from contaminated used PPE. 7. Four sharps' containers (used for safe disposal of used needles and syringes) in Rooms 122, 218, 221, and 234, were observed filled past the fill line indicator (a line marker indicating the container needs to be replaced). This failure had the potential risk for infections related to needlestick injuries (injuries caused by punctures from needles used in medical procedures). 1a. During an observation on April 10, 2023, at 6:30 AM, a Dialysis Caregiver 1 (DC 1) repeatedly failed to follow infection control practices, when DC 1 changed the CVC dressing, accessed the CVC, and connected the CVC blood lines (plastic tubes that connects residents to the hemodialysis machine) to Resident 216's CVC. Resident 216 was not wearing a mask. DC 1 did not perform hand hygiene in between seven glove changes and placed 10 opened sterile syringes on top of a non-sterile blue chux (a pad made of paper with a waterproof backing) and did not clean the exit site of Central Venous Catheter from the center towards the outside (an infection control techniques that requires to disinfect an open skin area from the least contaminated to the most contaminated skin area). During a review of Patient 216's face sheet (a document that contains resident's basic demographic information) indicated Patient 216 was admitted to the facility on March 29, 2023, with diagnoses that included end stage renal disease (kidneys can no longer function on their own), anemia ( deficiency of red blood cells), and encounter for attention to tracheostomy (a hole that surgeons make through the front of the neck and into the windpipes, a tracheostomy tube is placed into the hole to keep it open for breathing). 1b. During a concurrent observation and interview on April 10, 2023, at 7:15 AM, DC 2 was accessing and connecting the blood lines to Patient 220's CVC, without following infection control guidelines. He placed 10 cc sterile syringes on top of the non-sterile blue chuck/pad, along with a pile of non-sterile gloves, tape, opened gauge, and alcohol pads. Tips of the sterile syringes were touching the non-sterile gloves and non-sterile chuck/pad. DC 2 did not perform hand hygiene before donning (Putting on) and/or doffing (removing) gloves. DC 2, kept the same blue chuck/pad that was laying across Patient 220's lap during CVC access, folded it and placed it on the clear bag that was hanging on the machine, he stated, "I'll save and use it for the end of the treatment." During a review of Patient 220's face sheet (a document that contains resident's basic demographic information) indicated Patient 220 was admitted to the facility on April 4, 2023, with diagnoses that included chronic kidney disease,(kidneys can no longer function on their own), tracheostomy dependence (an opening surgically created through the neck into the trachea to allow air to fill the lungs) and congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). During a concurrent interview and record review with the Dialysis Registered Nurse 1 (DRN 1) on April 11, 2023, at 4:47 PM. The DRN 1 reviewed the facility's policy and procedure (P&P) titled, "Patients with a Central Venous Catheter (CVC)," effective date December 1, 2020, which indicated, "Purpose: To provide care to a resident with a Central Venous Catheter (CVC) ...5. The SNF RN/ Caregiver and the resident must be masked during initiation or termination of treatment, during dressing changes, and reversing the bloodlines." DRN 1 stated that Patient 216 wasn't wearing a mask during the initiation of treatment, the policy wasn't followed. During a concurrent interview and record review with the Dialysis Registered Nurse 1 (DRN 1) on April 11, 2023, at 4:47 PM. The DRN 1 reviewed the facility's policy and procedure (P&P) titled, "Dressings, Dry-Clean," effective date February 27, 2020, which indicated, "Purpose: The purpose of this procedure is to provide guidelines for the application of dry, clean dressings ...Steps in the Procedure: 1 ...Establish a clean field ...5. Wash and dry your hands thoroughly ...6. Put on clean gloves ...remove soiled dressing ...7. Pull glove over dressing and discard ...8. Wash and dry your hands thoroughly ...15. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated are (usually from the center outward) ...17. Apply the ordered dressing...18. Discard disposable items into the designated container ...19. Remove disposable gloves and discard ...wash and dry hands thoroughly ..." DRN 1 stated that DCs 1 and 2 didn't follow the policy. A request to provide a copy of the facility's policy and procedure indicating sterile technique to be observed while initiating, terminating, and administering intravenous medication (into the vein) through CVC, was made, but the facility was not able to provide. 2. During a concurrent observation, interview, and record review, on April 6, 2023, at 5:44 AM, with LVN 1, outside of Patient 30's room, Patient 30 was lying in her bed, and called out for LVN 1's assistance because she could not find her television remote. Outside of Patient 30's door was a facility sign titled, "Contact Precautions," dated May 30, 2019, which indicated when entering and leaving the room, everyone must clean hands and put on a gown and gloves at the door." LVN 1 told Patient 30 she would help her find her television remote. LVN 1 put on a pair of gloves, entered the room, picked up the remote on the resident's bedside table, and handed the remote to the resident. LVN 1 then removed her gloves, exited the room, and cleansed her hands with hand sanitizer. LVN 1 stated, the standard practice when entering an isolation room would be to wear a gown and gloves, but if there was no physical contact, then only wearing gloves was permissible. LVN 1 further stated, if a person enters an isolation room and touches something, the person should wear a gown and gloves. During an interview, on April 6, 2023, at 10:33 AM, with the Director of Nursing (DON), she stated, it was expected that any person who entered an isolation room, use all personal protective equipment (PPE-gowns, gloves, may include face mask or face shield) for the specific isolation organism. The DON further stated no one should have entered an isolation room without a gown because of the risk of infection transmission in the environment. During an interview on April 7, 2023, at 11:52 PM, with the Infection Preventionist Nurse (IP), the IP stated, if a person passed through the doorway into a contact isolation room, he/she must have their PPE on, which included a gown and gloves. The IP further stated, the risk of isolation precautions not being followed would be to potentially spread infections to those who entered the room without the correct PPE, their families, and everyone that person came in contact with. During an interview, on April 10, 2023, at 8:57 AM, with LVN 6 regarding isolation procedure, LVN 6 stated, if at any point a person went into an isolation room, they must have been, fully dressed in a gown and gloves. During an interview, on April 10, 2023, at 9:07 AM, with LVN 4, LVN 4 stated, after having exited an isolation room and all PPE was removed, sometimes the residents would ask staff to come back into the room for assistance. LVN 4 stated, when that happens, it was still expected that staff put on a gown and gloves before they entered the isolation room. During a review of Patient 30's medical record, the "Admission Record," (contains admission and demographic information), dated April 7, 2023, the "Admission Record" indicated, Patient 30 was admitted on March 15, 2023, with a diagnosis of enterocolitis (inflammation affecting the large and small intestine) due to clostridium difficile (bacterium that causes diarrhea and colitis) and osteomyelitis (inflammation of bone tissue caused by an infection). During a record review of Patient 30's "Order Summary Report," dated April 7, 2023, the "Order Summary Report" indicated, there was an order from a physician for the resident to be placed on Isolation for Contact Precautions with a diagnosis of Carbapenem-resistant Enterobacterales (CRE-a large order of different types of bacteria that commonly causes infections in healthcare settings) from March 16, 2023, until May 21, 2023. During a review of the facility's policy and procedure (P&P) titled, "Personal Protective Equipment," dated October 2018, the P&P indicated, " ...PPE required for transmission-based precautions is maintained outside and inside the resident's room." During a review of the facility document titled, "CDC [Center for Disease Control] Guideline for Isolation Precautions: Appendix A" indicated, "A Transmission-Based Precautions category was assigned if there was strong evidence for person-to-person transmission via droplet, contact, or airborne routes in healthcare or non-healthcare settings and/or if patient factors increased the risk of transmission." 3. During an observation and interview with LVN 1, on April 6, 2023, at 6:03 AM, inside Patient 417 and Patient 416's shared room, she had a tray with two medication cups with medications, labeled with the resident's room number, a glucometer (medical device used to monitor glucose in the blood), two lancets (sharp needle used to obtain blood for testing glucose), and two opened alcohol wipes. She placed the tray on Patient 417's bedside table and proceeded to check Patient 417's blood sugar. After LVN 1 administered Patient 417's medications, she picked up the tray and glucometer and placed them on Patient 416's bedside table and proceeded to check Patient 416's blood sugar. After LVN 1 checked Patient 416's blood sugar, she exited the room and placed the glucometer on her medication cart without cleaning or disinfecting the device. During an interview with LVN 1, on April 6, 2023, at 6:18 AM, when asked how often the glucometer was cleaned, LVN 1 stated, she cleaned the glucometer after the device was used in an isolation room and at the end of her shift. LVN 1 stated, she had to check seven more residents' glucose readings that morning. When asked to clarify if she would continue checking all seven residents' glucose without cleaning and disinfecting the glucometer, LVN 1 asked the surveyor to wait while she browsed the Internet on her personal cell phone. LVN 1 stated, she changed her answer, and that the glucometer should be cleaned after each resident use. During a concurrent observation and interview with LVN 1, on April 6, 2023, at 6:20 AM, LVN 1 proceeded to move her medication cart to the next room. When asked if LVN 1 will clean the glucometer before going into the next room, LVN 1 stated, "Right. It's a force of habit," and cleaned the glucometer with a bleach wipe. During an interview, on April 6, 2023, at 11:10 AM, with the Director of Nursing (DON), the DON stated, the glucometer should be cleaned and disinfected with bleach wipes after each use. During an interview, on April 7, 2023, at 11:41 AM, with LVN 8, LVN 8 stated, glucometers should be cleaned before use and between patient use with a [Name of cleaning and disinfecting wipe manufacturer] wipe and air dried for five minutes. During an interview, on April 7, 2023, at 11:52 AM, with the Infection Preventionist Nurse (IP), the IP stated, it was the expectation that staff cleaned the glucometer before and after every use and the risk associated with not cleaning the glucometer would be a potential for blood infections including HIV (human immunodeficiency virus - a virus that attacks the body's immune system) and hepatitis (inflammation of the liver). The IP further stated staff were also at risk when the glucometer was not cleaned and disinfected because staff usually first touch the glucometer without gloves. During a concurrent interview and record review of the [Name of cleaning and disinfecting wipe manufacturer] bleach wipes label, on April 13, 2023, at 11:05 AM, with LVN 14, LVN 14 stated, she cleaned the glucometer after each patient use with [Name of cleaning and disinfecting wipe manufacturer] bleach wipes. The [Name of cleaning and disinfecting wipe manufacturer] bleach wipes label, undated, indicated, the wipes were intended for use in healthcare settings and was EPA (environmental protection agency - developed and enforced environmental regulations) registered. The [Name of cleaning and disinfecting wipe manufacturer] wipes indicated, when used, the treated surface should remain visibly wet for three minutes and air dried. During a review of Patient 417's "History and Physical" (H&P), d