Champlain Valley Physicians Hospital Medical Center SNF
Deficiency Details, Certification Survey, June 30, 2011
Regional Office: Capital District Regional Office
F441 483.65: FACILITY ESTABLISHES INFECTION CONTROL PROGRAM
Severity: Potential for more than Minimal Harm
Corrected Date: August 5, 2011
The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (a) Infection Control Program The facility must establish an Infection Control Program under which it - (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) 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. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. (c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection.
Citation date: June 30, 2011
Based on observation and staff interview, during the standard recertification survey, the facility did not ensure that it established and maintained an infection control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of disease and infection during 3 observations. Specifically, the facility did not ensure that staff did not use a soiled linen hamper as a workstation, did not carry clean or soiled linens against their uniform, and did not ensure that staff washed their hands. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This is evidenced by:
The Policy and Procedure for Hand Hygiene dated 3/6/09, documented that hand washing must be performed before and after direct contact with residents, after contact with a resident or with body fluids or excretions, after contact with inanimate objects in the vicinity of a resident, and after removing gloves.
During an observation on 6/28/11 at 2:30 pm, Certified Nursing Assistant (CNA) #1 was observed using the soiled linen hamper in the hallway as a work station. The CNA was writing on a paper resting on the hamper and was leaning on the hamper in such a way that the uniform was in contact with the hamper.
During an interview with CNA#1 on 6/28/11 at 2:38 pm, she stated that she did not see a problem with using the hamper as a writing surface because it was not visibly soiled. She stated that if there was fecal matter or any other kind of secretions on the hamper, she would not have written on it or leaned on it.
During an observation on 6/28/11 at 2:48 pm, CNA #2 walked out of a resident's room, went into another resident's room and emptied a urinal without gloves on. The CNA then went to the kitchen, got ice and soda and took them to the second resident. The CNA did not wash his hands during this observation.
During an interview on 6/28/11 at 3:12 pm, CNA#2 stated that he normally washed his hands after resident contact and after handling a urinal, and must have just forgotten this time.
During an observation on 6/28/11 at 2:23 pm, CNA#3 was observed carrying soiled linens in a plastic bag against her uniform in the hallway. The CNA sat the bags on the hallway floor and went into another resident's room and adjusted the resident's positioning. The CNA did not wash her hands during this observation.
During an interview with CNA#3 on 6/28/11 at 2:29 pm, she stated that she was not aware that she could not carry the linens against her uniform if they were in a plastic bag. She also stated that she did not think to wash her hands because they were not soiled and she only repositioned the resident.
During an interview on 6/29/11 at 8:00 am, the Registered Nurse in Charge (RNC) stated that staff were supposed to wash their hands after resident contact and after removing gloves. She also stated that staff were not to allow soiled linens or the plastic bags the linens were carried in to come into contact with the uniforms. The RNC also stated that the soiled linen hamper should not be used as a work surface.
10 NYCRR 415.19(a)(1-3)