| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 017035 | (X3) Date Survey Completed 03/17/2022 |
| Name of Provider or Supplier Infirmary Home Health Agency, Inc. | Street Address, City, State 851 E I-65 Service Rd S, Suite 1000, Mobile, AL | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| G0682 | Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observations, review of agency policies and procedures and interviews, it was determined the agency failed to follow their policy on infection control including hand hygiene (HH), PICC (Peripherally Inserted Central Cather) line care, venipuncture and cleaning of devices. This deficient practice affected 1 of 2 patients reviewed with a PICC line, including Home Visit (HV) # 1 and and 2 of 7 HV observations for hand hygiene, including HV # 7 and HV # 2 and had the potential to negatively affect all patients served by the facility. Findings include: Agency Policy: Hand Hygiene Policy Number 8.004 Revised Date 5/1/19 Purpose: To help prevent the spread of microorganisms and infection by cross-contamination and to provide practice guidelines. Policy: Staff are required to perform hand hygiene prior to, at specified time points during, and following patient contact... Procedure: b. before performing an aseptic task (e.g., insertion of invasive devices,...) c. after contact with blood,... d. if moving from a contaminated body site to a clean body site during patient care. e. after contact with inanimate objects f. before and after removal of personal protective equipment (PPE).... Agency Policy: Dressing Change Procedure for Central Venous, Midline, and Peripherally Inserted Central Catheters Policy Number: 10.027 Revised Date: 10/1/16 Purpose: To keep insertion sites clean, stabilize catheters and minimize the risk of infection. Policy: ...Sterility will be maintained throughout this procedure... Agency Skills Quick Sheet: Blood Specimen Collection: Venipuncture Syringe Method Published Date: August 2021 31. ...perform hand hygiene, and don clean gloves. 34. Prepare the venipuncture site. a. Cleanse the site with friction using a gauze pad and 70% isopropyl alcohol solution. b. Allow the area to air-dry.... Do not touch the site after preparation unless sterile gloves are worn. Agency Policy: Infection Control Plan Policy Number 8.001 Revised Date 11/1/21 Purpose: To enhance the safety and quality of patient care provided by the agency... Policy: The agency will establish a comprehensive infection control program... Program Goals: ...Ensure proper sanitation of medical equipment, devices and supplies... 2. HV # 7 was admitted to the agency on 2/7/22 with admitting diagnoses of Abscess of The Breast and Nipple and Necrotizing Fasciitis. A HV was conducted on 3/16/22 with EI # 5, Licensed Practical Nurse (LPN) to observe wound care provided. On arrival to HV # 7's home EI # 5 was at his/her car with the trunk open. EI # 5 had gloves on and was obtaining supplies and bag from the trunk. EI # 5 entered the home with the gloves on used to close the trunk. EI # 5 entered the patient's bedroom and placed barriers on 2 chairs wearing the same gloves used to open and close the trunk of the car. After placing the 2 clean barriers on the chairs EI # 5 removed gloves and sanitized hands and donned clean gloves. EI # 5 placed the tablet for documentation on the dresser in a basket which contained the patient Home Health folder and other patient belongings without placing a barrier. EI # 5 donned clean gloves after sanitizing hands and removed the old dressing from the right breast area. EI # 5 disposed of old dressing, removed gloves and donned clean gloves and did not sanitize hands. EI # 5 cleaned the scissors and did not remove gloves or sanitize hands and cut the Alginate with scissors and placed on the wound using the same gloves to clean the scissors. EI # 5 removed gloves and sanitized hands. EI # 5 donned clean gloves and cleaned equipment and placed on the clean barrier. Once the cleaning of the equipment was complete, using the same gloves to clean the equipment EI # 5 picked up the clean equipment and placed in the nursing bag contaminating the equipment after cleaning. An interview was conducted with EI # 9, RN at 12:45 PM who confirmed EI # 5 should have changed gloves and sanitized after cleaning the wound, EI # 9 confirmed EI # 5 should have changed gloves and sanitized hands after cleaning the scissors and opening the Alginate and placing on the wound and prior to touching the clean equipment. 3. HV # 2 was admitted to the agency on 3/9/22 with admitting diagnoses of Essential Primary Hypertension and Unspecified Protein-Calorie Malnutrition. A HV was conducted on 3/15/22 at 9:07 AM with EI # 3, MSW (Medical Social Worker) to observe care provided. EI # 3 sanitized hands outside in the patient's yard and placed the bottle of hand sanitizer in pants pocket and then entered the home after opening the screen door and the front door with bare hands. EI # 3 then went to the patient's room and removed a barrier from the bag, placed barrier on a stack of items in the patient's room and placed the MSW bag on the barrier. EI # 3 did not sanitize hands after entering home and prior to placing the barrier on the stack of items. EI # 3 spoke with the patient at length and once the conversation was complete EI # 3 documented on the tablet. EI # 3 failed to sanitize hands prior to documentation on the tablet or after completion of the documentation. EI # 3 removed a garbage bag and from the MSW bag and placed the barrier in the partially opened garbage. EI # 3 went to the kitchen to talk with the caregiver and to sign the visit note in the tablet and the used barrier fell out of the garbage bag and on to the kitchen floor. EI # 3 picked up the barrier and again placed in the partially opened garbage bag and threw the bag in the home trash can. EI # 3 exited the home, removed the bottle of hand sanitizer from pants pocket and sanitized hands and placed bottle back in pocket. EI # 3 was heading to the car and the surveyor asked what EI # 3 was going to do with the tablet. EI # 3 said he/she was going to put it in his/her car, paused and stated the tablet would be cleaned and then removed an alcohol wipe and cleaned the tablet outside in the patient's yard and placed the used alcohol pad in the outside garbage can. An interview was conducted on 3/15/22 at 10:15 AM with EI # 1, Executive Director, who confirmed hand hygiene was not properly performed during the visit, The tablet should have been cleaned prior to use and after use in the home. 1. HV # 1 was admitted to the agency on 2/8/22 with diagnoses including Arthritis Due to Other Bacteria, Vertebrae and Essential (Primary) Hypertension. A HV was conducted on 3/15/22 to observe Employee Identifier (EI) # 2, Registered Nurse (RN) perform PICC line access and care and obtain blood specimens. EI # 7, Patient Care Manger (PCM) attended the visit with the surveyor. During the visit, EI # 2 performed HH and opened a sterile package containing individually wrapped sterile packages of supplies to perform PICC line care. EI # 2 placed a sterile barrier on the surface and without donning sterile gloves, removed the sterile packages from the sterile container and placed them on the sterile barrier. EI # 2 then performed HH and donned sterile gloves to open the sterile packages that were placed on the sterile barrier to complete PICC line care. EI # 2 then attempted to obtain a blood sample from the PICC line unsuccessfully and informed HV # 1 that a blood sample would be obtained from a venipuncture. EI # 2 doffed gloves, performed HH and cleaned the venipuncture site on the left hand with ChloraPrep and then touched the point of entry site with a gloved hand to palpate the vein. EI # 2 then performed a venipuncture attempt without re-cleaning the site. The attempt to obtain a blood sample was unsuccessful. EI # 2 then doffed gloves, performed HH, obtained clean venipuncture supplies, donned clean gloves and cleaned another site on the left hand with alcohol. EI # 2 then touched the cleaned area to palpate the vein and without re-cleaning the site, performed the venipuncture to obtain the blood sample, but was unsuccessful. Prior to ending the visit, EI # 2 cleaned the electronic device used to document the visit and handed the device to HV # 1 to sign the tablet and without cleaning the device, placed it in his/her pocket. An interview conducted on 3/15/22 at 2:15 PM with EI # 7 confirmed the nurse did not follow their policy for infection control including hand hygiene, PICC line care, venipuncture and cleaning reusable equipment. |