Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 013434	(X3) Date Survey Completed 02/01/2018
Name of Provider or Supplier River Region Family Medicine	Street Address, City, State 41 Cambridge Court, Wetumpka, 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)

J0055

PATIENT CARE POLICIES
CFR(s): 491.9(b)(1)

The clinic's ... health care services are furnished in accordance with appropriate written policies which are consistent with applicable State law.

This STANDARD is not met as evidenced by:
Based on observations, the facility policy and procedure manual, review of Potter and Perry's Fundamentals of Nursing, Center for Disease Control (CDC) and interviews with the staff it was determined the facility failed to ensure their policy and procedure was followed for infection control and to ensure all staff followed appropriate infection control procedures for handwashing and glove changing. Findings include: Hand washing: Policy and procedures Ivy Creek Healthcare Purpose: To cleanse the hands of germs and prevent contamination between patients and home care personnel. Policy: All personnel providing direct or indirect care/ service will wash their hands...prior to contact with the patient. Personnel also will wash their hands: after gloves are removed when hands are visibly soiled... Potter and Perry's FUNDAMENTALS OF NURSING EIGHTH EDITION, Chapter 28. Copyright 2013, "Infection Prevention and Control " page 419 revealed: " ...Change gloves and perform hand hygiene between tasks and procedures on the same patient after contact with materials that contains a high concentration of microorganisms. Remove gloves promptly after use, before touching non-contaminated items ...Perform hand hygiene immediately to avoid transfer of microorganisms..." Hand Hygiene CDC Guidelines Last updated: March 25, 2016 When to Perform Hand Hygiene a. Before Eating b. Before and after having direct contact with a patient's intact skin (taking pulse or blood pressure, performing physical examinations...) c. After contact with blood, body fluids or excretions, mucous membranes, non-intact skin or wound dressings. d. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. e. After glove removal... 1. A patient observation with Patient Identifier (PI) # 21 was conducted on 1/31/18 at 10:55 AM with Employee Identifier (EI) # 4, Medical Assistant. PI # 21 was taken to the triage area for vital signs and medical information concerning the visit. EI # 4 did not have gloves on and took PI # 21's vital signs and documented on the computer. EI # 4 then donned gloves and did not wash hands prior to donning the gloves and conducted a flu swab. EI # 4 escorted PI # 21 to an exam room to be seen by the nurse practitioner. The surveyor observed EI # 4 entering the exam room with a syringe. The surveyor observed EI # 4 don gloves without sanitizing hands and gave PI # 21 an injection of Decadron and Medrol to the right hip. EI # 4 removed gloves and failed to wash hands prior to leaving the exam room. 2. A second observation was conducted on 1/31/18 at 11:30 AM with EI # 4 and PI # 22 to observe the drawing up of medication and administration to the patient. EI # 4 was in the triage room and sanitized hands and began to draw Decadron from the bottle and failed to clean the rubber stopper prior to insertion of the needle. EI # 4 then inserted same needle into a second bottle which contained Medrol and drew the medication up and failed to clean the rubber stopper of the bottle prior to insertion of the needle. When complete EI # 4 removed gloves and donned a clean pair of gloves without sanitizing hands. EI # 4 entered Exam room to administer the medication. EI # 4 with the same gloves on administered the medications to PI # 22 to the left hip area. EI # 4 removed gloves and failed to sanitize hands prior to leaving the exam room. 3. A patient observation was conducted on 2/1/18 at 8:05 AM with EI # 8, Medical Assistant, and PI # 23 to observe the patient visit. The patient was brought to the triage room and EI # 8 took PI # 23's vital signs and documented in the computer and did not wash or sanitize hands before or after vital signs were taken. EI # 8 then reviewed the patient's medications with the patient and escorted the patient to exam room # 6 to be seen by the nurse practitioner. EI # 8 returned to the triage room and documented on the computer and failed to sanitize hands. EI # 8 then obtained forms and placed them in a folder for review by the nurse practitioner and returned to triage room where EI # 8 donned gloves without sanitizing hands and drew up a B 12 injection in a 3 cc (cubic centimeter) syringe without cleaning the rubber stopper of the medication bottle. At 8:30 AM EI # 6, nurse practitioner, entered the exam room to speak with PI # 23. EI # 6 had a tablet in hands for documentation. EI # 6 placed the tablet on the counter in exam room # 6. EI # 6 failed to sanitize hands prior to entering patient's exam room. EI # 6 assessed the patients lungs and heart and spoke with the patient for several minutes. EI # 6 then documented on a form and in the tablet and failed to sanitize hands before or after assessment of the patient and before documenting on the tablet. EI # 6 failed to clean the tablet after sitting the tablet on the counter and prior to exiting the exam room. An interview was conducted on 2/1/18 at 1:15 PM with EI # 1, Assistant Manager, who confirmed the above mentioned findings.