How tor ead

s Got
oFaci
li
ty Got oFacil
ity'
sLi
st
Got
oCitat
ion' ins
pect i
on/ Pri
nting
Pl
anof ofInspecti
onsand
Regul
ati
on occurrence Ins
truct
ions
Corr
ect
ion Occurrences
resul
ts

Ci
tat
ion'
sText
Pl
eas
eus
eli
nksandt
absabovet
onavi
gat
ethi
ssear
cht
ool
.Donotus
ebr
ows
erbac
kbut
ton.

Facil
ityID:020317
Facil
ityName:CENTENNI ALHEALTHCARECENTER
Ins
pect i
onID:S OPE11
Ins
pect i
onExitDat e:2/13/2020
Citat
ionCode:0880
Citat
ionTitl
e:InfectionPrevent
ion&Cont
rol
ScopeandSever i
ty(S/S)
:D

Not
es:Ci
tat
ionc
ode"
0000"and"
9999"ar
eini
tialandf
inalComment
sofani
nspec
tion.

Ci
tat
ionText
onobs er
vati
ons,recordrevi
ew andi
nterv
iews,thefacil
it
yfail
edt oensur
einf
ec t
ioncontr
olprac
tic
eswerees
tabl
ishedandmaint
ainedtoprov
ideasafe,
sanit
aryandc omfort
ableenvir
onmenttohelppreventthedevelopmentandtransmis
sionofcommunic
abl
edis
easesandinf
ect
ionsfortwo(#1and#2)of
threeresi
dentsobservedforwoundcareof15totalsampleres
idents.

S
pec
ifi
cal
ly,s
taf
fdi
dnotf
oll
ow pr
operhandhy
gienepr
act
iceswhi
lepr
ovi
dingwoundc
are.

Fi
ndi
ngsi
ncl
ude:

Fac
ili
typol
ici
es

TheWoundCare/Treat
mentGuideli
nespol
icy
,lastrevi
sedFebruar
y,2018,waspr
ovidedbytheadmi
nis
trat
orint
rai
ning(AI
T)viaemai
lon2/18/2020.I
tread
i
npart,"Handhygi
eneshoul
dbeper f
ormed.Suppl
iesarenottobeplacedonthebed.Suppl
iess
houl
dbeplacedonac l
eansur
face.Abl
ueabsorbentpador
waxpaperprovi
desacleanbar
rier
."

TheHandHy gi
enepol i
cy,lastrevisedFebruary,2018,waspr ovidedviaemai lbytheAI Ton2/18/2020.Itreadi npart,"
Pur pose:Todec reasetheriskof
tr
ans missionofinfec
tionbyappr opr i
atehandhy giene.Policy:Handwas hing/handhy gieneisgenerall
yconsideredthemos ti mpor t
antsingl
epr oc
edur efor
prevent i
ngheal t
hcareassoci
atedi nfecti
ons.Was hingwiths oapandwat erisappropriatewhent hehandsar evisi
blysoil
edorc ontaminatedwithbloodor
otherbodyf l
uids.Usi
nganal cohol-basedhandr ub( ABHR)isappr opriatefordecontami nati
ngthehandsbef oredirectpatientc ontac
t;beforeputtingon
gl
ov es;aftercontactwithapat ient;whenmov ingf r
om ac ontami nat
edbodys i
tetoac leanbodys i
teduri
ngpat ientcare;afterc ont
actwi t
hbodyf l
uids,
excretions,muc ousmembr anes,noni ntactski
n,wounddr es s
ings;afterremovingglov es;andaftercont
actwi thinanimateobj ectsinthepat i
ent'
s
environment ."

Obs
erv
ati
ons

On2/11/2020at2:50p.m.woundc
areobs
erv
ati
onsf
orRes
ident#2wer
emadewi
thr
egi
ster
ednur
se(
RN)#1,whowast
hef
aci
li
ty'
swoundnur
se,andt
he
woundcarephysi
cian(WCP)
.

RN#1was hedherhandsanddonnedgl ov
esthenr
eachedintot hepocketofherscrubtopforthewoundcleanserbottl
eandat ubeofwoundoi nt
ment.
Withoutchanginghergloves,RN#1thenspray
edthewoundc leanseronthewoundandc l
eanedthewoundwi thagauzepad.Wi thoutt
akingoffthegl
oves
thatshehadj ustusedtoc l
eanthewound,RN#1proceededtoappl ythewoundointmentt othewoundandc overitwithadr
es s
ing.RN#1t hendis
car
dedthe
dress
ingsuppliesi
nt hetr
ash,andremovedhergl
oves.Sheplac edthewoundcleanserbott
leandtubeofwoundoi ntmentbackinherscrubpocketbefor
e
washingherhandsandex iti
ngtheroom.

At3:
15p.
m.woundc
areobs
erv
ati
onsf
orRes
ident#1wer
emadewi
thRN#1,l
icens
edpr
act
icalnur
se(
LPN)#2andt
heWCP.

RN#1r emovedtheol ddr

essi
ngfrom thecoccy
xanddi dnotsani
tiz
eherhandsorc hangehergl
ovesafters heremovedt
heol ddr
ess
ing.Us i
ngthesamegl oves
sheusedtoremov etheolddress
ingfrom t
hewound,RN#1gott hes uppli
essheneededoutofapl as
tictubt hatwasset
tingonthebedsidetable.She
reac
hedintohers cr
ubpocket,pull
edoutt hes
pr aybot
tleofwoundc l
eanser,andproceededtocl
eanset hewoundandappl yanew dres
s i
ng.Shereturned
thewoundcleansertoherscrubpocket.RN#1t henremovedhergloves,usedABHR,andputonanew pai rofglov
es.

RN#1heldupt her esi

dent'
sleftlegfort
heWCPt oassesst
heheelwound.Af t
ertheassess
mentwasc omplet
ed,RN#1r
eachedintoherscrubpoc ketagai
n
andremovedthes praybottleofwoundc l
eans
er.Shethenproc
eededt ohandthespraybottl
etoLPN#2,whohadnotchangedherglovesorperformedhand
hygi
eneaf
t erass
istingwiththeposit
ioni
ngoftheresi
dentandpri
ortoengagingwiththewound.LPN#2s prayedt
hewoundcleans
eront helef
theelandRN
#1usedagauz epadt ocleansethewound.RN#1t ookthewoundcleanserbackandretur
nedittoherpocket.

Resi
dent#1washavi
ngpai
nduringtheass
essmentoft
hewoundont hetopofthef
oot.TheWCP,whohadnotchangedhi
sgl
ovesandper
for
medhand
hygi
ene,reac
hedint
othepoc
ketofhislabcoatwit
hhisdi
rtygl
ovesandproc
eededtoremov
eas pr
aycanofnumbingspr
aywhic
hheusedonthewoundpr
ior
toretur
ningt
hecantohi
spocket.

Uponcomplet
ionoftheasses
sment,RN#1againreachedint
ohers c
rubpocket
,pull
edoutt hebott
leofwoundc leans
er,spr
ayedi
tont hewound,cleaned
thewoundwithagauzepad,andreturnedthebot
tletoherpocketwit
houtchangi
ngherglovesandperfor
mi nghandhygi
ene.RN#1thenwentt otheplast
ic
tubtogetnew dr
ess
ingsuppl
ies
.Withoutremovi
ngherglovesorwashi
ngherhands,shebegansearchi
ngthroughthetubforthes
uppl
iessheneeded.When
RN#1didnotf
indwhatsheneeded,LPN#2removedhergl
ovesbutdidnotperf
orm handhy
giene bef
orel
ooki
ngt
hrought
het
ubofc
leans
uppl
ies
.RN#1
thenr
emovedhergl
oves
,didnotperfor
m handhy
giene,andconti
nuedtolookthr
oughthetub.

S
taf
fint
erv
iews

RN#1wasi nt
ervi
ewedon2/11/2020at5: 20p.
m.Shes ai
dthathandss
houl
dbewas hedbef
ores
tar
tingadr
ess
ingchange.S
hesaidt
hatglov
esshoul
dbe
changedandhandssani
ti
zedafterremov
ingadres
sing,aft
ercleani
ngawound,andbegi
nni
ngtr
eat
mentonadi f
fer
entwound.Shesai
dthathandss
houl
dbe
washedbefor
eleavi
ngar es
ident'
sroom.

LPN#2wasinterv
iewedon2/11/2020at5:55p.m.Shesai
dthatshehadworkedatthef
aci
li
tyforaboutni
nemont
hsandhadr
ecei
vedhandhy
gienet
rai
ning
oncedur
ingthatti
me.Shesai
ds herec
eivedthetr
aini
nguponhir
ewhens hewasgiv
enhandout
sonhandwas hi
ngt
oread.

S
hes aidthati
fshewasdoingadres
singchanges
hewoul
dwashherhandswhensheenter
edtheroom,putongl
oves
,andthenwashherhandsagai
nbef or
e
l
eavingtheroom.Shesai
dt hati
faresi
denthadmor
ethanonewound,shewoul
dchangeglov
esbefor
emov i
ngf
rom acont
aminat
edbodysit
etoac leanbody
s
ite.

Thedi
rec
torofnur
sing(
DON)
,whowasal
sot
hef
aci
li
ty'
scer
tif
iedi
nfec
tionc
ont
rolpr
event
ioni
st(
ICP)
,wasi
nter
viewedon2/13/2020at9:
00a.
m.

TheDONs
aidthats
heperfor
medr andom audi
tswi
ths
taf
f,obs
ervi
nghandhygi
enepr
acti
ceswhenshewasoutonthefl
oor
,andt
hats
heal
way
sremi
nded
st
afft
owasht
heirhands
.Shesai
ds hewoulddooneononeeducat
ioni
fshenoti
cedahandwashi
ngis
suewit
has t
affmember
.

S
hesaidthattheprot
ocolforhandhygi
enef ornursesperf
ormingdr
ess
ingchangeswouldbeforthem t
owashthei
rhandsbefor
ebeginni
ngthedres
sing
c
hangeandt henputongloves
.Shesaidthatnursesshoul
dc hanget
hei
rgloves
,useABHR,andputonnew glov
esafterremov
ingadressi
ng.Shes
aidthatt
hey
s
houl
dc hangethei
rglov
esandus eABHRc hangeglovesbefor
emov i
ngfrom acont
aminatedbodysi
tetoacl
eanbodys i
te.

TheDONsaidt
hatshehadbeendoingwoundr
oundswitht
heWCPunti
lafew weeksagowhenRN#1t ookover
.Shesaidshehadobs
erv
edRN#1onet
ime
si
nceshet
ookoverforwoundr
oundsandhadnotnot
icedanyc
onc
ernswi
thherdressi
ngchangeorhandhygi
eneprac
tices.

Shesaidthatst
affwaseducatedannuallyinregar
dst ohandwashi
ngwhichincl
udedwhent owashhands
,how towash,andwhentowashwi
thsoapand
waterver
s usus
ingABHRtos anit
izehands.Shesaidthatmoreeducati
onwasneededwi t
hthestaf
f.Sheals
os ai
dthatshewoul
dcal
ltheWCPandlethi
m
know oft
hei nf
ecti
oncontr
olc oncer
ns,andi nf
orm hi
m offaci
li
tyexpect
ati
onsforhandhygi
eneandwoundc areprac
tices
.