Choice Health at Home

“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 record review, observation and interview, the Agency failed to follow accepted standards of practice, including the use of standard precautions to prevent the transmission of infections and communicable diseases for 2 of 7 (Patient # 4 and Patient #6) patients whose records were reviewed for infection control in that: LVN A failed to follow wash her hands after removing gloves and upon finishing wound care that was provided to Patient #4. LVN A failed to follow wash her hands after removing gloves and upon finishing wound care that was provided to Patient #6. These deficient practices could place active patients, and most importantly, patients with wounds and/or those with weakened immune systems at risk of infections and hospitalizations. The findings included: Record review of Agency policy titled, “Infection Control Program IC.10”, with a revised date 05/01/24, quoted in part, “The Agency’s infection control program will be based on the following criteria…D. CDC guidelines updated annually… F. The Occupational Safety and Health Administration (OSHA), 29 CFR Part 1910.1030 and Appendix A relating to Bloodborne Pathogens…G. Current federal, state, and local laws and regulations…” Record review of Patient #4’s electronic medical record included a “Physician Order” signed and dated 08/22/24 that documented the following orders: Right foot 4th interspace ulcer (wound) and lateral ulcer: cleanse wound with vashe (type of wound cleanser), pat dry, apply santyl (ointment used to help remove dead skin and aid in wound healing), adaptic (non-adherent dressing), kerlix (type of woven gauze), and tape. Plantar wound: apply calcium alginate (water-insoluble, gelatinous cream used in wound healing) and DSD (dry sterile dressing) three (3) times a week. Record review of Patient #4’s “Home Health Certification and Plan of Care” (POC) signed and dated 10/21/24 indicated a start of care date 08/08/24 and a current certification period of 10/07/24 through 12/05/24. Furthermore, the POC documented a primary diagnosis of “type 2 diabetes mellitus with foot ulcer” (a condition resulting from insufficient production of insulin that causes high blood sugar and breakdown of skin in the foot). The POC documented skilled nurse frequency/duration of visits as follows, two visits per weeks for eight weeks (2wk8) and one week for one week (1wk1). The POC documented the following orders of discipline and treatments: Skilled nurse (SN) to perform/teach pressure ulcer care to right foot (area), cleanse with wound cleanser, apply gauze, cover with kerlix (woven bandage gauze), using clean/aseptic technique, change dressing Monday and Friday and prn (as needed). SN to report wound abnormalities to MD. SN may discontinue wound care once wound has healed or patient/caregiver demonstrate competency with own wound care. During a home visit to Patient #4 on 11/25/24 at 11:05 a.m., an observation was made of LVN A performing wound care to Patient #4’s right foot. Upon arrival to the home visit, LVN A and Surveyor A were escorted to Patient #4’s bedroom where he was observed sitting supine in a large armchair. After introductions were briefly made, LVN A set up her field on a disposable pad on a side table. LVN A proceeded to assess Patient #4’s body functions, pain level, vital signs, and right foot that was resting on the floor. LVN A then sanitized her hands, donned (put on) gloves, removed the soiled dressing from Patient #4’s right foot (LVN A failed to place clean pad between environment and patient’s foot to set clean field). LVN A continued by adjusting the trash bin closer to her reach and disposed of soiled dressings in Patient #4’s home trash bin (LVN did not remove the soiled gloves doff, don, or sanitize her hands after adjusting trash bin). LVN A cleansed 1st wound of right foot between 4th and 5th toe with 4x4 gauze and vashe. LVN A continued to cleanse second wound of right plantar foot with 4x4 gauze and vashe. LVN A then removed soiled gloves and proceeded to further assess wounds by taking pictures with her tablet. Once all pictures were taken, LVN A sanitized hands, donned new gloves and measured 1st wound of right foot between 4th and 5th toe with 1st sterile cotton tipped applicator. LVN A proceeded to measure 2nd wound of right plantar foot with 2nd sterile cotton tipped applicator (LVN A did not change gloves or sanitize hands between wound 1 and wound 2). LVN A followed by packing wound #2 of right plantar foot with iodoform packing (sterile absorbent packing strips coated with a yellowish powder with antiseptic properties used to pack open wounds) using sterile cotton tipped applicator. LVN A continued packing wound #1 of right foot between 4th and 5th toe with iodoform packing using cotton tipped applicators. LVN A then applied adaptic gauze to this wound, covered both wounds with dry 4x4 gauze. LVN A completed the procedure by securing the gauze by rolling a Kerlix gauze over the entire right foot and placing a tape over it. LVN A then doffed (removed) her gloves, sanitized her hands, put wound care supplies away, wiped the area, wiped her supplies, and put them away in her bag. LVN A finished her procedure and excused herself from Patient #4’s home (LVN A did not wash her hands upon finishing wound care or double bag soiled dressings in Patient #4’s trash bin prior to leaving the home). In an interview on 11/25/24 at 11:20 a.m., Patient #4 stated Agency provided wound care services to his right foot since approximately July 2024. Patient #4 stated he was happy with services provided by Agency. Patient #4 stated he had no complications or changes in his wound since the start of his care and that nurses would notify his physician if there were any changes. Record review of Patient #6’s “Home Health Certification and Plan of Care” (POC) signed and dated 10/24/24 indicated a start of care date 01/24/24 and a current certification period of 09/20/24 through 11/18/24. Furthermore, the POC documented a primary diagnosis of “disruption of external operation (surgical) wound, nec, (not elsewhere classified) init (initial encounter)” (surgical complication where the surgical incision may have pulled apart). The POC documented skilled nurse frequency/duration of visits as follows, two visits for one week (2wk2), three times a week for seven weeks (3wk7), and one times a week for one week (1wk1). The POC documented the following orders of discipline and treatments: Skilled nurse to perform wound care to back wound as follows: cleanse area with wound cleanser or NS (normal saline), irrigate wound using vashe, pack wound using ½ plain packing impregnated with silversorb gel (silver-based gel used to treat wounds), cover with ABD (abdominal) pad and secure with tape. Wound care to be scheduled 3Xs week MWF (Monday/Wednesday/Friday) as requested by the patient. SN to report wound abnormalities to MD, SN may discontinue wound care once wound has healed, or patient/caregiver demonstrate competency with own wound care. Record review of Patient #6’s POC signed and dated 11/114/24 documented the following orders of discipline and treatments: Skilled Nurse to perform/teach wound care to lower back – cleanse with wound cleanser, apply packing, cover with bordered bandage, using aseptic technique, change dressing 3 times weekly and prn. Record review of Patient #6’s electronic medical record included a “Physician Order” signed and dated 11/18/24 that documented the following orders: Cleanse wound using wound cleanser, irrigate wound with vashe, pack wound using ¼ inch packing strip impregnated with silversorb gel, cover with silicone or gauze bordered dressing. May use ABD pad if drainage increases. 3xs (times) a week or prn (as needed). During a home visit to Patient #6 on 11/25/24 at 11:55 a.m., an observation was made of LVN A performing wound care to Patient #6 mid lower (lumbosacral) region of her back. Upon arrival to the home visit, LVN A and Surveyor A were escorted to Patient #6’s bedroom where she was observed to be sitting supine in a large armchair. After introductions were briefly made, LVN A set up her field on a disposable pad on the far side of the patient’s bed. LVN A proceeded to assess Patient #6’s body function, pain level and vital signs. Patient #6 then transferred from the armchair to lying on her left side (or left Sim’s position) onto the closer side of the bed. LVN A brought wound care supplies close to Patient #6 and set them on the bed (LVN A failed to place clean pad between environment and patient to set clean field). LVN A sanitized her hands, donned new gloves, removed the soiled dressing, and set it on the bed close to the patient (no pad used under patient as barrier and did not change gloves or sanitize hands prior to next step). Using her tablet, LVN A took pictures of the wound and then measured the wound using a sterile cotton tipped applicator. LVN A then cleansed the wound with wound cleanser and 4x4 gauze. LVN A picked up soiled dressing and gauzes, walked towards Patient #6’s trash can (sitting by armchair), and disposed of soiled dressings and gauzes (LVN A did not change gloves or sanitize hands after disposing soiled dressings). LVN A picked up trash can and brought Patient #6’s trashcan closer to the bed where she was performing wound care (LVN did not doff, don, or sanitize her hands after adjusting trash bin). LVN A drew vashe into a sterile syringe and irrigated the wound with the solution. LVN A patted the wound with a dry 4x4 gauze, cut iodoform packing, applied silvasorb to the packing and packed the wound with the impregnated packing. LVN A then sprayed skin prep around the wound and prepared 4x4 gauze on a piece of mefix (self-adhesive fabric) tape. LVN A covered the wound with the prepared 4x4 gauze and mefix tape. LVN A put all used supplies in trash can and clean supplies in Patient #6’s storage container on the far side of the bed (LVN A did not change gloves or sanitize hands after wound care). LVN A doffed gloves, sanitized hands, documented on her tablet, wiped, and stored her supplies in her bag. LVN A finished her procedure and excused herself from Patient #4’s home (LVN A did not wash her hands upon finishing wound care or double bag soiled dressings in Patient #6’s trash bin prior to leaving the home). In an interview on 11/25/24 at 12:00 p.m., LVN A stated she had done Patient #6’s wound care “many times”. LVN A stated Patient #6 used to have “purulent, thick drainage” and had no drainage at this time. In an interview on 11/25/24 at 12:05 p.m., Patient #6 stated she currently had no pain to her surgical site. Patient #6 stated she had no history of infections or problems with her surgical site. Patient #6 stated she had been admitted to the Agency a year ago for wound care. Patient #6 stated she had no issues with the nurses that took care of her and was happy with the services she received from the Agency. In a follow up interview on 11/25/24 at 02:40 p.m., LVN A stated she had been employed with the Agency for 18 months and had been in-serviced on hand hygiene and infection control upon hire. LVN A stated the Agency offered weekly review on infection control topics including antibiotics, hand hygiene, wound care, etc. LVN A stated hand hygiene included making sure they washed or sanitized their hands before seeing a patient to prevent the transmission of bacteria. LVN A stated the Agency did not require the use of a biohazard bag for soiled wound care supplies if they went into the trash. LVN A stated “to be honest” it probably does need to be double bagged. LVN A stated “I was nervous, I was throwing everything away” during wound care of both Patient #4 and Patient #6. LVN A stated I don’t think my gloves were soiled. LVN A stated I should have sanitized my hands between glove changes. LVN A stated, “I don’t think I needed to have changed gloves” when performing wound care for Patient #4 between wound #1 and wound #2 because “both wounds were cleansed already”. LVN A stated, “yes” there was a risk for infection. LVN A stated there was a break in the chain of infection when she went to bring the trashcan. LVN A stated, “I did not sanitize my hands”. LVN A stated there was an increased risk of infection and that the patients could get an infection. In an interview on 11/25/24 at 02:59 p.m., the Adm/DON stated Agency wide in-service on infection control was performed upon hire for each employee and every quarter or at minimum yearly during their QAPI meetings. The Adm/DON stated other Agency wide in-services performed every quarter were hand hygiene, bag technique, cleaning your section, wiping your equipment, using a barrier, do not put a bag on floor, etc. The Adm/DON stated soiled dressings should be discarded in simple trash bag, discard as a double bag, close it correctly discard it correctly and outside of patient’s home. The Adm/DON stated hand hygiene consisted of washing hands for 20 seconds, turning off water with paper towel, using alcohol-based rubs if hands were not soiled. The Adm/DON stated staff were able to sanitize hands up to three times during wound care before being required to wash their hands. The Adm/DON stated staff were instructed to remove soiled dressings with dirty gloves, apply new gloves to clean site, remove gloves, sanitize, get new gloves, apply bandage, remove gloves, and wash hands. The Adm/DON stated she was responsible for performing in-service to staff and would provide in-services for infection control for LVN A. The Adm/DON stated not performing proper hand hygiene and not disposing of soiled dressings according to agency policy increased risk of infections, hospitalizations, and delayed healing among Agency patients. In an interview on 11/27/24 at 01:10 p.m., the Alt Adm stated LVN A did not follow Agency policies regarding hand hygiene. The Alt Adm stated LVN A did not follow Agency policies regarding wound care. The Alt Adm stated LVN A did not follow Agency policies regarding disposal of soiled dressings because she did not double bag. The Alt Adm stated LVN A did not follow Agency policies regarding infection control because she did not correctly dispose of soiled dressings and perform adequate hand hygiene. The Alt Adm stated the failure of LVN A in following Agency policies increased the risk of infections, delayed healing, and increased the risk of hospitalizations among Agency patients. The Alt Adm stated the Agency used Reference 1 as a source of reference for their procedures including wound care and hand hygiene. In a follow up interview on 11/27/24 at 01:20 p.m. the Adm/DON stated LVN A did not follow Agency policies regarding hand hygiene. The Adm/DON stated LVN A performed the actual procedure, except the clean technique was not performed and, therefore, LVN A did not follow Agency policies regarding wound care. The Adm/DON stated LVN A did not double bag because she was nervous and forgot in the moment. The Adm/DON stated LVN A did not follow Agency policies regarding disposal of soiled dressings. The Adm/DON stated LVN A did not follow Agency policies regarding infection control. The Adm/DON stated the failure of LVN A in following Agency policies increased the risk of patient hospitalization and risk of infections. Record review of LVN A personnel file included a “Skilled Nursing Competency Checklist” signed and dated 10/09/24 that documented LVN A was competent for the following skills: infection control…hand hygiene, proper bag technique, use of personal protective equipment, exposure plan…” Further review of LVN A personnel file included a Job description/Performance Evaluation signed and dated 10/09/24 that documented “provides care using infection control measures that protect both staff and patient/client…I have read the above job description and essential functions. I understand and agree to carry out these responsibilities as assigned...” Review of form “Hand Hygiene Competency Checklist” signed and dated 09/26/24 documented LVN A was competent in performing “hand hygiene with soap and water” skills. Review of “meeting sign in sheet” signed and dated 09/26/24 documented LVN A attended meeting for “Case Conference/Infection Control Policy”. Review of OSHA 29 CFR 1910.1030, titled Bloodborne pathogens, accessed 12/04/24, quoted in part, “Regulated waste…contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials...(d)(2)(iv) When provision of handwashing facilities is not feasible, the employer shall provide either an appropriate antiseptic hand cleanser in conjunction with clean cloth/paper towels or antiseptic towelettes. When antiseptic hand cleansers or towelettes are used, hands shall be washed with soap and running water as soon as ...(d)(2)(v) Employers shall ensure that employees wash their hands immediately or as soon as feasible after removal of gloves or other personal protective equipment…(d)(2)(vi) Employers shall ensure that employees wash hand and any other skin with soap and water, or flush mucous membranes with water immediately or as soon as feasible following contact of such body areas with blood or other potentially infectious materials….(d)3(ix) Gloves. Gloves shall be worn when it can be reasonably anticipated that the employee may have hand contact with blood, other potentially infectious materials, mucous membranes, and non-intact skin; when performing vascular access procedures except as specified in paragraph(d)(3)(ix)(D); and when handling or touching contaminated items or surfaces…. (d)(4)(iii) Regulated waste…” Review of Lippincott Advisor and Lippincott Procedures titled “Hand Hygiene, Home Care”, with a revised date 02/19/23, quoted in part, “Washing with soap and water is appropriate when the hands are visibly soiled or contaminated with blood or other body fluids, when exposure to potential spore-forming pathogens (such as Clostridioides difficile or Bacillus anthracis) is strongly suspected or proven, and after using the restroom. Using an alcohol-based hand rub is appropriate for decontaminating the hands before direct patient contact; before putting on gloves; before inserting an invasive device; after contact with a patient; when moving from a contaminated body site to a clean body site during patient care; after contact with body fluids, excretions, mucous membranes, nonintact skin, or wound dressings (if hands aren’t visibly soiled); after removing gloves; and after contact with inanimate objects in the patient’s environment. The WHO simplifies points of hand hygiene into five key moments….1. Before touching the patient…2. Before clean/aseptic procedure…3. After body fluid exposure risk…4. After touching a patient...5. after touching patient surroundings…” Review of Lippincott Advisor and Lippincott Procedures titled “Standard Precautions, home care”, with a revised date 08/18/22, quoted in part, The Centers for Disease Control and Prevention (CDC) developed standard precautions to protect against the transmission of infection. Standard precautions are a group of infection prevention practices based on the idea that all blood, body fluids, secretions, excretions (except sweat), nonintact skin, and mucous membranes may be infectious. CDC officials recommend that health care workers assume that all patients, regardless of their diagnosis, are potentially infected or colonized (carrying an organism but not showing signs or symptoms of infection) with an organism that the patient may transmit to others. Standard precautions include hand hygiene, appropriate use of personal protective equipment (PPE), and proper handling of potentially contaminated items, including patient equipment, items in the environment, sharps, and specimens… Perform hand hygiene before and after patient care; before putting on and after removing gloves; before handling an invasive device; when moving from a contaminated body site to a clean body site; after contact with body fluids, excretions, mucous membranes, nonintact skin, or wound dressings (even if you wore gloves); and after contact with inanimate objects in the 12/4/24, 5:00 PM Lippincott Procedures - Standard precautions, home care patient’s environment. If your hands aren’t visibly soiled, use an alcohol-based hand rub for routine hand hygiene. If they’re visibly soiled, wash them with soap and water and dry them with a paper towel…. Change your gloves and perform hand hygiene if your gloves become damaged or heavily soiled and when moving from a contaminated to a clean site during patient care to avoid cross contamination. Avoid touching your face, body, and other surfaces and items not needed for direct patient care with your gloved hands to reduce the risk of transmitting infectious organism… Place waste contaminated by blood, body fluids, or other potentially infectious materials (such as soiled dressings, incontinence supplies, and used tubing and catheters) into a waste container lined with a plastic biohazard bag. Avoid overfilling the container. Review of Lippincott Advisor and Lippincott Procedures titled “Wound dressing application, home care”, with a revised date 02/19/23, quoted in part, “Organize the equipment and supplies on a clean surface. Place a fluid-impermeable pad between the environment and the equipment and supplies, if necessary. Arrange the equipment and supplies according to the order of use to avoid cross-contamination while performing wound care…Perform hand hygiene…Put gloves on and as needed, other personal protective equipment to comply with standard precautions…Place a fluid-impermeable pad under the wound to prevent soiling…Discard the soiled dressing in the sealable waterproof trash bag…remove and discard your soiled gloves…perform hand hygiene…put on new gloves…Assess…clean the wound…Discard the soiled gauze in the sealable waterproof trash bag…remove and discard your soiled gloves…perform hand hygiene…put on new gloves…” The agency did not dispute the survey findings and did not provide this surveyor with any additional requested documents upon exit.”