HospitalInspections.org

Based on observation, staff interview and policy review, the facility failed to ensure staff were appropriately trained in infection prevention procedures during 1 of 1 observation of resident care (#1). The findings were:

1. Observation on 9/7/21 at 2:15 PM showed CNA #1 assisted resident #1 in the restroom. The CNA donned gloves and removed the resident's pants and brief. The CNA removed her gloves and did not perform hand hygiene. The CNA then donned another pair of gloves, performed perineal care and put a clean brief on the resident and pulled his/her pants up. The CNA then removed the gloves, did not perform hand hygiene, assisted the resident to the wheelchair, and touched clean clothes in the resident's closet. The CNA performed hand hygiene upon exiting the room. Interview with the CNA at that time revealed she was taught to "gel in" and "gel out." She was never taught to perform hand hygiene after touching contaminated items and before putting clean gloves on. Interview with the DON on 9/7/21 at 4:05 PM revealed she did not fully understand the process of performing hand hygiene when moving from a contaminated area to a clean area, or when changing gloves.

2. Review of the Hand Hygiene Policy dated 8/8/21 showed, "A. Clean hands hands before and after routine patient care activities, including...after hand-contaminating activities...B. Glove use does not replace the need for hand hygiene...F.All hospital and medical personnel are to perform hand hygiene:...11. When moving from a contaminated body site to a clean body site...14. Before and after using gloves...".

Based on observation, medical record review, staff interview and policy and procedure review, the facility failed to ensure staff reviewed and updated the comprehensive assessment and care plans at least annually for 4 of 5 residents reviewed (#1, #2, #3, #4). The findings were:

1. Observation on 9/7/21 at 2:15 PM showed resident #1 required a sit-to-stand mechanical lift to assist with transfers. Medical record review showed the resident was admitted on 7/1/18 with diagnoses which included hypertension and cerebral vascular accident. Further review of the medical record showed a comprehensive assessment was completed on admission, and further review of the medical record failed to show a yearly comprehensive assessment. Medical record review showed a care plan with the last review date of 7/24/19. Review of the care plan failed to show the resident required a sit to stand mechanical lift for transfers.

2. Review of the medical record for resident #2 showed the resident was admitted on 7/1/18 with diagnoses which included anxiety, insomnia, diabetes and congestive heart failure. Further review of the medical record showed an admission comprehensive assessment and care plan was completed. Further review failed to show yearly comprehensive assessments were completed. Further review showed the care plan was last reviewed on 3/22/19.

3. Review of the medical record for resident #3 showed the resident was admitted on 1/2/19 with diagnoses which included cognitive disorder, chronic obstructive pulmonary disease, and hypertension. Further review showed an admission comprehensive assessment and care plan was completed on 1/2/19. Further review of the medical record failed to show a yearly comprehensive assessment, or an updated care plan.

4. Review of the medical record for resident #4 showed an admission date of 9/27/19 with diagnoses which included opioid dependency, pain, diabetes mellitus type 2 and chronic renal insufficiency. Review of the medical record failed to show an admission comprehensive assessment, and care plan.

5. Interview on 9/7/21 at 4:05 PM with the DON revealed she was new to the position and was not aware the residents required a comprehensive assessment with an significant change, or yearly. She also stated she was not aware the care plans needed to be updated and revised.

6. Review of the policy titled Documentation Standards, with a revision date 9/16, showed "...all patients admitted to the NCH Skilled Swing Bed unit, will have a documented initial and a periodic, comprehensive, accurate, standardized, reproducible assessment and a patient oriented care plan."

7. Review of the policy titled Care Planning with a revision date 8/19, showed, "...1. on admission an interim nursing care plan be developed by an RN...2. A comprehensive assessment will be completed within 14 days and...the care plan completed within 21 days of admission...8. The written nursing care plan will be reviewed...at least weekly by nursing staff...".