Wedgewood Nursing Home

Based on observations, staff interviews, and record reviews, it was determined that for two of two observations of glucometer (machine to test a resident's blood sugar level) testing, one of two observations of incontinence care, and one of two meal observations, the facility did not use appropriate infection control techniques to prevent the potential transmission of infection. Issues included the improper disinfecting of the glucometer between resident use, staff that did not remove soiled gloves prior to touching environmental surfaces, and improper cooling of hot food prior to feeding a resident. This affected Residents #4, #11, and #12, resulting in a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

1. During observation of the medication pass on 9/26/11 at 11:30 a.m., the Licensed Practical Nurse (LPN #1) obtained a blood sample on Resident #11 using the Microdot glucometer to test the resident's blood sugar level. After obtaining the blood sample, LPN #1 cleaned the glucometer using an alcohol pad. She then proceeded to test Resident #12. After obtaining the blood specimen, LPN #1 again cleaned the glucometer with an alcohol pad.

On 9/27/11, LPN # 2 was observed doing a glucometer reading on Resident #12. After obtaining the blood sample, LPN #2 cleaned the glucometer using an alcohol pad.

When interviewed on 9/27/11 at 10:45 a.m., the Director of Nursing (DON), who functions as the Infection Control Nurse, stated that the facility does not have a procedure for disinfecting glucometers.

During an interview on 9/28/11 between 8:40 a.m. and 8:42 a.m., LPN #2 and LPN #3 both said they clean glucometers with an alcohol pad.

Review of the facility's policy entitled, "Contact Precautions guidelines," dated 4/26/04, documented that if use of common equipment is unavoidable, these items should be adequately cleaned and disinfected before using for another resident.

Review of the undated "Microdot Blood Glucose Meter Medical Product's Policy," to healthcare professionals advises to clean blood glucose meters between each resident test using isopropyl alcohol and to disinfect the meter with a 1:10 dilution of bleach and water or other commercial germicidal product to avoid cross contamination.

2. Resident #4 has diagnoses including dementia. Review of the Minimum Data Set (MDS) Assessment, dated 8/26/11, revealed that the resident has severely impaired cognition, is incontinent of urine, and totally dependent on staff for personal hygiene.

During personal care on 9/26/11 at 1:05 p.m., a Certified Nursing Assistant (CNA) was observed handling the resident's soiled brief, cleansing the resident's buttocks area of urine, and applying ointment. Without removing her soiled gloves, she then touched the resident's clothing, bed linens, and a personal bed alarm. When interviewed at 1:25 p.m., the CNA stated that she realized she touched the clothes, bed linens, and bed alarm prior to removing her gloves and should not have.

3. During observation of meal time on 9/26/11 at 12:25 p.m. in the main dining room, Resident #4 was being fed by a CNA who repeatedly blew on several individual bowls and spoonfuls of the resident's pureed food to cool it down.

When interviewed on 9/27/11at 2:15 p.m., the DON stated that she expects staff to remove their dirty gloves after peri care and wash their hands before touching anything in the room. She also stated that staff blowing on food to cool it down was not acceptable.

Review of the facility's policy entitled, "Handwashing," undated, revealed that staff are to wash hands after handling soiled linens and providing personal care.

[10 NYCRR 415.19(b)(2)(4)]

Based on staff interview and record reviews, it was determined that for one of ten residents reviewed for professional standards, the facility did not provide services that met professional standards of quality. The issue involved an incorrect transcription of a physician's medication order (Resident #8). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Resident #8 was readmitted to the facility on 9/13/11 with diagnoses including chronic constipation and dementia.

Review of physician's orders, signed 9/14/11, revealed an order for Senna S (laxative with a stimulant) two tablets by mouth once daily. Physician orders, dated 9/19/11, included Colace (stool softener) 200 milligrams (mg) by mouth once daily and does not include an order for Senna S.

Review of the Medication Administration Records (MAR), dated September 2011, revealed an order for Colace 200 mg by mouth once daily that was discontinued when the resident was admitted to the hospital on 9/9/11. Also included was a transcription of the order for Senna S two tablets by mouth once daily. The Senna S entry on the MAR was initialed daily from 9/19/11 through 9/27/11 to show that the medication was administered.

During an interview on 9/27/11 at 12:45 p.m., the Registered Nurse/Nurse Manager (RN/NM) stated the current physician order is for Colace, not Senna S. The RN/NM did not know why Colace was not written on the MAR. In another interview that day at 1:00 p.m., the Director of Nursing (DON) stated that when the resident was readmitted on 9/13/11, she completed the admission orders by speaking to the physician. The DON did not know why the Colace was changed to Senna S. The DON stated that the 9/19/11 orders should include Senna S. After surveyor intervention, the physician was called, and an order was written for Senna S two tablets by mouth once daily. The DON stated that there is no policy on transcription of orders, it is just an expectation of practice and would be covered on orientation.

[10 NYCRR 415.11(c)(3)(i)]
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Based on observations made during the Life Safety Code Survey, it was determined that the facility did not provide compliant exit lighting. The issue was related to exit lighting that was controlled by a switch. This affected one of two exits from the basement level, and resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy and is isolated. The findings are:

Observations on 9/26/11 at 10:15 a.m. revealed the lighting in the exit stairway, located in the basement adjacent to the staff restroom/locker room, was controlled by switches on the wall at the top and bottom of the stairs. When switched to the off position, the stairway was in total darkness except for a small amount of natural light from a window in the door at the top of the stairs. At the base of the stairway was a sign that read, "Do not turn lights out." This stairway serves as one of two required exits from the basement level, and there is an illuminated exit sign directing occupants to this stairway located in the hall across from the maintenance shop. Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use.

[10 NYCRR 415.29(a)(2), 711.2(a)(1); 2000 NFPA 101: 19 .2.8, 7.8.1.2]