Lewis County General Hospital-Nursing Home Unit

Based on observations, record reviews, and staff interviews conducted during the standard survey, it was determined the facility did not establish and maintain an infection control program designed to prevent the development and transmission of disease and infection for 1 (Resident #1) of 4 sampled residents observed for pressure ulcer dressing changes, and for 1 resident (Resident #25) of 4 residents observed for infection control concerns. Specifically, staff did not follow proper infection control technique during Resident #1's wound care; the facility did not ensure staff observed proper infection control technique during Resident #25's fingerstick blood glucose testing. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

THIS A REPEAT DEFICIENCY FROM THE OCTOBER 29, 2009 SURVEY.

Findings include:

1) Resident #1 had diagnoses including diabetes mellitus, dementia, and end-stage renal disease.

The facility policy, "Dressings, Clean Technique," dated September 2007, documented staff were to use a barrier over the work space used to place supplies for a dressing change; were to change gloves and wash hands between removal of a soiled dressing, and the application of treatments/dressings to the wound.

The resident's 60-day Minimum Data Set (MDS) assessment, dated November 11, 2010, documented the resident had moderate cognitive impairment; required extensive staff assistance for activities of daily living (ADLs); and had an unstageable pressure ulcer.

Physician's orders, dated November 22, 2010, included an order for a daily dressing change to the resident's left hip pressure ulcer, including the application of Santyl ointment.

The comprehensive care plan (CCP), updated on December 1, 2010, documented the resident had the potential for skin tears related to thin, frail skin; had several small open areas on her buttocks; and an unstageable pressure ulcer on her left hip. Interventions included inspection of skin for signs of infection and treatment as ordered.

During the initial unit tour at 10:00 AM on December 6, 2010, the registered nurse (RN) Unit Manager identified the resident as having an unstageable pressure ulcer on her left hip.

At 10:00 AM on December 8, 2010, a surveyor observed the dressing change to the pressure ulcer on the resident's left hip, performed by the licensed practical nurse (LPN) treatment nurse, in the presence of the registered dietitian (RD) and a certified nurse aide (CNA). The LPN was observed to drop wrapped gauze packages on the floor, then pick them up and place them on the resident's overbed table, which contained no barrier. The LPN applied gloves and picked up the gauze packages from the overbed table. She then picked up a tube of Santyl and a paper measuring device. The LPN removed the dressing from the resident's left hip, and used the paper measuring device to measure the pressure ulcer. Without changing her gloves and washing her hands, the LPN opened the gauze packages that were previously on the floor, applied saline solution, and cleansed the wound with the gauze. The LPN then picked up the tube of Santyl, removed some ointment, and applied it to the wound with a cotton-tipped applicator. The CNA opened a package of gauze. The LPN then applied the gauze to the resident's wound, without changing her gloves and without washing her hands.

At 10:30 AM on December 8, 2010, a surveyor interviewed the LPN treatment nurse about the dressing change she performed earlier that morning. The LPN stated she should not have:
- picked up packages of dressings from the floor and put them on the resident's overbed table;
- placed wound care supplies on the overbed table without using a barrier;
- performed wound treatment with gloves that touched contaminated materials;
- cleansed the resident's wound and applied ointment and gauze without changing her gloves and washing her hands.

At 10:30 AM on December 8, 2010, a surveyor interviewed the RN Unit Manager regarding the resident's dressing change observations earlier that morning. The RN told the surveyor that the LPN should have used a barrier on the resident's overbed table, and observe proper infection control technique, including changing of gloves and proper hand hygiene.

In summary, staff did not follow proper infection control technique during wound care.

2) Resident #25 had diagnoses including diabetes mellitus.

The facility policy, "Precision PCX Pro (brand of glucometer) - Patient Testing Procedure," revised June 2010, documented that upon completion of fingerstick glucose testing, the glucometer was to be cleaned with a 10% bleach solution.

During observation of the medication pass at 5:10 PM on December 6, 2010, the medication licensed practical nurse (LPN) used a glucometer to obtain the resident's fingerstick glucose testing at the nurses' station. Without cleaning the glucometer, the LPN placed it on top of the medication cart, and rolled the cart into the medication room at 5:22 PM.

At 5:45 PM on December 6, 2010, a surveyor interviewed the LPN medication nurse who completed the resident's fingerstick glucose testing that evening (see above). When the surveyor asked the LPN when the glucometer should be cleaned, the LPN stated, "I will clean it before the next use." When asked about placing the glucometer on top of the medication cart without cleaning it, the LPN stated, " I didn't think it was a problem."

In summary, the facility did not ensure staff observed proper infection control technique during fingerstick blood glucose testing.

10 NYCRR 415.19 (a)

Based on observations, staff interviews, and record reviews conducted during the standard survey, it was determined the facility did not provide adequate supervision and assistance to prevent accidents for 2 of 8 sampled residents (Residents #21 and 2) identified at risk for aspiration (inhalation of foreign matter into the lungs). Specifically, the facility did not assess Resident #21 for proper positioning during/after meals; did not provide a swallow evaluation to assess the resident's symptoms; and did not develop and implement a care plan for the resident's aspiration risk. For Resident #2, the facility did not ensure she consistently received the accurate fluid consistency as planned. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #21 had diagnoses including dementia and poor dentition.

The resident's most recent swallow evaluation, dated June 23, 2009, documented the resident was referred to the speech language pathologist (SLP) due to her refusal to take solid food via a spoon. The SLP recommendation was to continue the resident's pureed diet, with solids thinned to a drinkable consistency PRN (as needed).

The comprehensive care plan (CCP), dated November 11, 2010, documented the resident had a food and nutritional related knowledge deficit related to dementia. Approaches included the use of a "cut out" cup and provision of a pureed diet; with solids thinned to a drinkable consistency. The CCP did not include instructions for assessing the resident's positioning during meals, and did not include the need to monitoring the resident for signs and symptoms related to choking or aspiration.

At 8:55 AM on December 7, 2010, a surveyor observed the resident sitting in a geri chair in the dining room. A certified nurse aide (CNA) fed the resident pureed breakfast items in the presence of a staff licensed practical nurse (LPN #1). The surveyor observed the resident positioned at a 45-60 degree angle. When asked about the resident's positioning at that time, LPN #1 told the surveyor the resident was not positioned upright, because she "shakes herself out of the chair." During the surveyor's meal observation, which concluded at 9:05 AM that morning, the resident was not observed to move in her chair.

The surveyor observed the resident alone in her room at 9:10 AM on December 7, 2010, following the breakfast meal. The resident was positioned at a 45 degree angle in her geri chair, and was observed to cough twice.

At 1:00 PM on December 7, 2010, the resident was observed in her geri chair in the dining room, elevated at a 45-60 degree angle, as she was fed lunch by a CNA.

The resident's annual Minimum Data Set (MDS) assessment, dated December 8, 2010, documented she had severe cognitive impairment; deficits in long and short term memory; was totally dependent on staff for assistance in eating and drinking; had discomfort or difficulty with chewing; and received a mechanically altered diet.

At 1:20 PM on December 8, 2010, a surveyor observed the resident in her geri chair as she was fed lunch in the dining room by LPN #2, in the presence of the registered nurse (RN) Unit Manager. The resident was positioned at a 45-60 degree angle.

At 1:30 PM on December 8, 2010, a surveyor interviewed the RN Unit Manager and LPN #2 about the resident's positioning as she was fed. The nurses told the surveyor the resident was elevated at a 45 degree angle, as if she was positioned upright, she would slide out of the chair.

At 1:40 PM on December 8, 2010, a surveyor interviewed the Director of Nursing (DON) about the most recent physical therapy evaluation of the resident's positioning. After reviewing the resident's physical therapy records, the DON stated there was no physical therapy note since November 6, 2008.

A surveyor interviewed the physical therapist (PT) Assistant Director of Rehabilitation at 1:50 PM on December 8, 2010 regarding the resident's positioning in her geri chair, as she was fed in the dining room. The resident was present during this interview and observed to cough during it at 1:50 PM and at 2:00 PM. The PT told surveyor that the resident "could choke. We need to get her head up more." The PT stated she would recommend the resident receive a swallow evaluation.

In summary, the facility did not ensure the resident received supervision and assistance to minimize the risk of choking/aspiration as:
- the resident was not assessed for proper positioning when she coughed during/after meals;
- the resident did not receive a swallow evaluation to assess symptoms of coughing at meals;
- care plan interventions were not developed and implemented to monitor the resident for risk of choking/aspiration.

2) Resident #2 had diagnoses including stroke, severe mental retardation, dysphagia (difficulty swallowing), and history of recurrent aspiration pneumonia.

A swallow evaluation, completed by the speech language pathologist (SLP) on September 28, 2010, documented the resident was hospitalized for aspiration pneumonia in July 2010; had a history of silent aspiration; and drank pudding-thickened fluids independently. Recommendations included continuation of pudding-thickened fluids; hand chopping soft foods to 1/2 inch or less; and draining liquids from fruits and vegetables.

The quarterly Minimum Data Set (MDS) assessment, dated October 5, 2010, documented the resident had severe cognitive impairment; required staff supervision for eating/drinking; and coughed or choked during meals or when swallowing medications.

The comprehensive care plan (CCP), dated October 14, 2010, documented the resident had the potential for alteration in nutrition due to her diagnoses of dysphagia and severe mental retardation. Interventions included provision of pudding-thickened fluids.

During the initial unit tour at 10:00 AM on December 6, 2010, the registered nurse (RN) Unit Manager identified the resident as receiving pudding-thickened fluids.

A surveyor observed the resident in the dining room during the supper meal at 6:00 PM on December 6, 2010. The resident's meal slip documented she was to receive ground foods and pudding-thickened fluids. Included with her meal was a 6 ounce bowl of chili. The fluid portion of the chili was observed to be of regular consistency. At 6:15 PM that evening, a surveyor interviewed the Assistant Director of Nursing (ADON) regarding the consistency of the chili. The ADON stated the chili was not pudding-thickened. At 6:20 PM, during the same meal, when a surveyor interviewed the Director of Nutritional Services about the consistency of the resident's chili, the Director removed the chili and stated the resident should not have received it.

In summary, for a resident with a history of dysphagia and recurrent aspiration pneumonia, the facility did not ensure she consistently received fluids of the consistency that was care planned.

10 NYCRR 415.12 (h)(1),(2)