Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated survey completed on April 5, 2019, in response to a complaint, it was determined that Brookline Manor and Rehabilitation Services was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

 Plan of Correction:

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards;

483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Based on observation, interview, record review, and policy review, it was determined that the facility failed to follow the infection control guidelines for prevention of infections for one of five residents reviewed, (Resident 3) and failed to follow guidelines for the storage of resident linens for one of two linen closets observed (Wing 3).

Findings include:

Review of the facility policy on April 5, 2019, at 1:00 PM titled, "Infection Control Guidelines for All Nursing Procedures," last revised August 2012, states that employees must wash their hands for 10 to 15 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: after removing gloves; after contact with blood, body fluids, secretions, mucous membranes, or secretions; after removing gloves; and before donning sterile gloves.

Review of the facility policy on April 5, 2019, at 1:00 PM titled, "Central Venous Catheter Changes," last revised April 2016, states to open the sterile dressing kit; apply mask; apply sterile gloves. The policy also states that "once the sterile gloves are on, only the contents of the kit may be touched. Do not pick up the catheter with the sterile gloves. The outside of the catheter is not sterile. Use sterile gauze to pick up catheter when cleaning underneath the catheter to preserve the sterile gloves."

Review of the clinical record for Resident 3 on April 5, 2019, at 9:00 AM revealed diagnoses that included Sepsis and Atherosclerotic Heart Disease. Resident was also admitted to the facility with a PICC (a Peripherally Inserted Central Catheter) to administer antibiotics.

Observation of the dressing change to the PICC line on April 5, 2019, at 11:00 AM revealed the following steps taken by Registered Nurse (RN) 1:

Initially, RN 1 gathered her supplies and placed them on the clean and covered bedside table. RN 1 washed her hands for 15 seconds, nonsterile gloves were donned, and the soiled PICC line dressing was removed with the presence of a moderate amount of red drainage. No mask was donned. The soiled dressing that was removed was dated, "3/27/19 and initialed XX," RN 1 confirmed that Resident 3 was admitted to the facility on March 29, 2019, and that the PICC line was initially inserted prior to admission, when Resident 3 was at the hospital. Following the soiled dressing removal, that was placed in a clear plastic bag, RN 1 removed her gloves and immediately donned another pair of non-sterile gloves without washing her hands. RN 1 then picked up the end of the PICC line with the non-sterile gloves and wiped the distal part of the catheter with an antiseptic wipe that is provided in the sterile dressing kit. RN 1 then removed her gloves and donned the sterile gloves from the sterile dressing kit without washing her hands. RN 1 picked up the catheter with her sterile gloves and cleansed the insertion site with the antiseptic wipe; placed the gauze around the catheter at the insertion site; applied the op site (clear dressing) and removed her gloves and no handwashing was observed. The dressing was then dated and initialed.
RN 1 then cleared the bedside stand of the remaining items and placed them in the clear plastic bag. RN 1 was followed to the soiled utility room where she was observed placing the soiled dressing into the regular trash. RN 1 then did wash her hands prior to leaving the soiled utility room.

During an interview with the Nursing Home Administrator on April 5, 2019, at 2:30 PM she revealed that the facility policy's for changing the PICC line dressing, and handwashing, should be followed.

Observation on April 5, 2019, at 11:10 AM revealed that the clean linen closet door was open on Wing 3, which is a resident corridor. On April 5, 2019, at 2:30 PM the same linen closet door was found open.

During an interview with the Nursing Home Administrator on April 5, 2019, she revealed that the linen closet doors should remain closed at all times.

28 Pa. Code 211.10(d) Resident Care Policies

28 Pa Code 211.12(d)(5) Nursing Services

 Plan of Correction - To be completed: 04/30/2019

There was no harm to Resident 3. Education provided to RN 1 pertaining to policies for "Central Venous Catheter Changes" and "Infection Control Guidelines for Nursing Procedures". DON or designee observed RN 1 completing competency of PICC dressing change, washing of hands, and proper disposal of soiled dressings into infectious waste.
To prevent occurring with other residents the DON or designee will observe the RN Supervisors completing a competency of PICC dressing change following the "Central Venous Catheter Changes" policy and "Infection Control Guidelines for Nursing Procedures". As an audit the DON or designee will observe RN Supervisors performing PICC dressing changes 2 times a week for 4 weeks, then 2 times a month for 1 month. DON or designee will provide education, followed by competencies, to newly hired RN's regarding policies "Central Venous Catheter Changes" and "Infection Control Guidelines for Nursing Procedures". When the RN Supervisor have their annual performance evaluation the DON or designee will observe their competency of the policies "Central Venous Catheter Changes" and "Infection Control Guidelines for Nursing Procedures".
Results of competencies and audits will be reported at the monthly QAPI meeting.
Nursing staff educated to follow infection control guidelines by closing the door to the linen closet upon leaving the closet. A sign posted on the door of linen closets indicating the door is to be closed. DON or designee will complete random observation audits of the linen closet door daily for 5 days with re-education as needed, then 3 x week for 1 week, then weekly for 2 weeks, then monthly for one month. Results of the audits will be reported at the monthly QAPI meeting.

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