East Haven Nursing & Rehabilitation Center

Based on observation, record review, and staff interviews,, the facility did not ensure that infection control practices were maintained during a dressing change observation. Specifically, the Licensed Practical Nurse (LPN) did not utilize appropriate hand hygiene technique, and did not remove her gloves and wash her hands after cleansing the resident's pressure ulcer with Normal Saline (NS). This was evident for 1 (one) of 2 (two) residents observed during a dressing change (Resident #191).

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident # 191 is an 89 year old with diagnoses which include: Failure to Thrive, Anemia, Dementia, and a Stage IV Sacral Pressure Ulcer.

The Minimum Data Set (MDS) 3.0 dated 8/13/11 documents that the resident has cognitive impairment and requires total assistance with all activities of daily living. The MDS further documented a stage IV pressure ulcer.

A Physician's order dated 8/19/11 documented, "Cleanse Sacral ulcer with NS. Apply collagenase Cover with dry dressing at 8PM and when necessary."

The Comprehensive Care Plan for "Impaired Skin Integrity- Actual" dated 5/16/11 documented "Wash hands/ wear gloves before and after touching affected area."

A dressing change observation was conducted on 8/22/11 at approximately 11:30AM. After cleansing the resident's sacral pressure ulcer with Normal Saline, the LPN did not remove her gloves and wash her hands before proceeding with the remainder of the wound care.

At approximately 11:40 AM, during an observation of hand hygiene, the LPN washed her hands by applying soap and immediately rinsed her hands under the water for approximately 5-7 seconds and then dried her hands with a paper towel.

On 8/22/11 at 1:30 PM, the LPN who had performed the dressing change was interviewed. She stated that she knew the proper procedure for handwashing, but did not use this technique in its entirety because she wanted to finish the procedure and was nervous. She stated that she normally washes her hands with a copious amount of soap and rubs them together for approximately 15-20 seconds. The LPN further stated that she should have taken more time to cleanse her hands and used more soap and friction when washing them. She also stated that she missed a step in the dressing change procedure by not removing her gloves, washing her hands and putting on new gloves after cleansing the wound.

On 8/22/11 at approximately 2 PM, the Registered Nurse (RN) / Assistant Director of Nursing (ADNS) was interviewed. The RN stated that the nurses are taught to wash their hands for a minimum of twenty seconds and to use soap, water, and friction before rinsing them. The ADNS further stated that the nurse should have removed her gloves, washed her hands, and put on clean gloves after cleansing the resident's wound.

The "Competency: Clean Dressing Technique" form dated and signed by the LPN on 8/9/11 documented "...cleanse the wound center to periphery...remove gloves and discard in plastic bag...wash hands then don non sterile gloves...apply dressing as ordered..."

The "Competency Evaluation for Handwashing" form dated and signed by the observed LPN on 7/17/11 documented, "use generous amount of soap...wash hands for at least 20 seconds, clean under and around finger nails, and rinse with your hands down, so that runoff goes into sink, and not down your arms..."

The Policy and Procedure for "Infection Control - Hand Washing" dated 6/2008 documented, "Hand Hygiene Technique:...When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers..."

415.19(a)(1-3)

Based on observation and interview, it was determined that the facility did not ensure that hazardous areas are protected as per 19.3.2.1 in that the doors to hazardous areas (in a fully sprinklered building) were not maintained to self-close and latch positively to resist the passage of smoke.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

During the life safety code inspection conducted on 08/18/11 between 9:00am and 3:00pm, it was observed that the doors to hazardous areas were not maintained to self-close and positively latch thereby compromising the smoke resistivity of such enclosures/areas. Examples include but are not limited to:
1) Door to the linen room (room measures over 50 sq ft) in the basement section was not equipped with a self-closing device. This room was noted to store numerous boxes of diapers, clean linen and pillows.
2) Door to the laundry room which was equipped with a self closing device, did not close when tested. The self-closer did not function and a gap of approximately 10 inches was observed between the door and its frame.
3) Door to the elevator machine room (kitchen elevator) was equipped with a self-closer. This door did not self close when tested. At approximately 10:10am, the Director of Operations stated that the self-closer on the door was wrongly installed. He added that it will be corrected.
4) Door to the 1st floor soiled utility room did not close and positively latch. The door did not fit into its frame. Furthermore a hole of approximately 1 inch radius was observed on the door. Other doors in which holes of approximately 1 inch were noted were the pantry room doors from floors 2 to 4. These compromise the smoke resistivity of the doors.
5) Door to the kitchen porter's closet did not close tightly and positively latch when tested. The latching device did not stick into the strike plate.

In an interview with the Director of Operations at approximately 10:15am, he stated that there is no preventive maintenance schedule maintained for door checks. He added that all issues noted would be fixed immediately and later indicated that the doors had been fixed.

NFPA 101 2000: 19.3.2.1
10NYCRR 711.2(a)(1)

(a) Cylinders. Cylinders shall be designed, constructed, tested, and maintained in accordance with 4-3.1.1.1(a).
Cylinders in service shall be adequately secured. Cylinders in storage shall be secured and located to prevent them from falling or being knocked over.

Based on observation and interview it was determined that the facility did not ensure that Oxygen cylinders (' e'cylinders) were securely stored to prevent accidental fall or being knocked over.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

During the Life Safety Code inspection conducted on 08/18/11 at approximately 10:55am, it was observed that four oxygen 'e ' cylinders (in the oxygen storage room located off the recreation room) were not securely stored to prevent accidental falls and/or being knocked over. The cylinders were stored on the floor.

In an interview with the DON on 08/18/11 at approximately 11:00am, she stated that the oxygen tanks are to be stored in carts and off the floor.

NFPA 1999 4-3.1.1.8(a)
711.2(a)(1)

Based on observation, interview and record review, it was determined that the facility did not ensure that all gauges of the wet pipe automatic sprinkler system are tested or replaced every 5 years as required by NFPA 25. (Inspection, testing and maintenance of water-based fire protection systems). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

On 8/18/11 between 11:45 am and 12:45 pm during the annual survey, it was observed that the building is fully sprinklered. A review of the facility maintenance records and interview with the Plant operations Director, on 8/18/11 at approximately 12:45 pm could not confirm that the gauges at the sprinkler piping system have been replaced every 5 years, or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

NFPA 25: 5.3.2
711.2(a) (1)

Based on observation, it was determined that the facility did not ensure that the door to the service opening of the linen chute on the 1st floor is maintained to close tight and latch positively in order to provide for the one hour fire resistance rating construction of the chute.
This resulted in no actual harm with potential for greater than minimal harm that is not immediate jeopardy.

The finding is:

On 08/18/11 at approximately 12:30pm, it was observed that the door to the service opening of the linen chute on the 1st floor did not close tightly and positively latch when tested. The plate that holds the latching device in place was missing.

In an interview at the same time, the maintenance staff stated that the plate that held the door latch in place came off and that it would be replaced. He stated that issues with equipment noted in the units were reported by the nursing staff to the engineering unit and that they are fixed immediately. He added that there are no preventive maintenance schedules maintained to check doors to the service opening of the linen chute.

711.2 (a)(1)

2000 NFPA 101 LSC Chapter 7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on record review and staff interview, the required annual test conducted for not less than 1hours for the battery-powered emergency lightings installed in the facility was not conducted. Reference is made to lack of documentation detailing that the test was done.
This resulted in no actual harm with potential for minimal harm.

The findings are:

During the review of facility maintenance logs on 08/18/11 at approximately 1:00pm, it was observed that documentation was not provided indicating/detailing that the required annual test (conducted for not less than 1hours) for the battery-powered emergency lighting installed in the facility generator room was conducted. Also, the duration of the test conducted on the battery-powered emergency lighting on a monthly basis was not indicated in the documentation provided for monthly tests.

In an interview with the Director of Operations at the same time, he stated that they do not conduct the required annual test on the battery-powered emergency lighting. He added that the battery-powered emergency lighting is tested monthly while conducting the generator test and that he presses the button for a second to see that it is working.

711.2(a)(1)