Superior Nursing Care

“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 written policies to control infections including how to keep infections and communicable disease from spreading, including the use of standard precautions to prevent the transmission of infections and communicable diseases for 2 (Patient 2 and Patient 3) of 5 active Patient whose records were reviewed for infection control in that: 1. RN A failed to follow aseptic technique (Aseptic technique is a procedure that healthcare providers use to prevent the spread of germs that cause infection.) while performing a Intravenous Bolus Medication administration to Patient #2. (IV bolus injection allows for the rapid administration of a drug directly into a vein through the proximal injection port on a continuous infusion administration set or through an intermittent vascular access device using a syringe.) 2. RN A failed to Follow and maintain Sterile Technique (A sterile technique is the use of practices and procedures that inhibit microorganisms in a specific environment and prevent contamination. Minimize potential exposure of infections and bloodborne borne pathogens.) while completing a suprapubic Foley Catheter care and change for Patient 3. (A suprapubic Foley catheter is a medical device used to drain urine from the bladder through a small incision in the abdomen, bypassing the urethra. This method is often employed when the urethra is damaged or when a patient cannot urinate on their own.) These deficient practices could place active Patient s at risk of exposure and infection and inadequate care when infection control practices are not applied The findings included: Record review of Patient #2’s electronic medical record included a “Home Health Certification and Plan of Care” (POC) initiated on 04/16/25 that documented a start of care date of 04/16/25 and a certification period of 04/16/25 through 06/14/25. Furthermore, the POC documented a principal diagnosis of Encounter for adjustment and management Of Venous Access Device (A VAD is a surgically implanted device that makes it easier to receive intravenous treatment and frequent blood testing) with Furosemide [AE1] injection (Medication used to treat excess fluid held in the body tissues) IV push daily for 7 days, The POC documented the following orders for disciplines and treatment: SN frequency: 4 times a week for 1 weeks, 3 times a week for 1 week and 1time a week for 7 weeks. SN to wash hands for 20 seconds using proper handwashing technique, disinfect equipment and don CDC recommended PPE. SN to perform Skilled head to toe assessment Q (every) visit using standard precautions. SN Using aseptic technique and using sterile supplies, SN to prepare / administer Lasix IV 10 Mg/ML 6 ML IV daily X 7 days over 6 minutes. Slow Iv Push using a 23–25-gauge butterfly catheter, SN to flush catheter with 5 ml of normal saline pre and post infusion of medication. SN to disinfect all equipment prior to placing in nursing bag, remove all PPE, dispose of all waste per OSHA guidelines, and wash hands for 20 seconds using proper hand hygiene. During a home visit to Patient #2 on 04/17/25 at 10:20 a.m., [AE2] an observation was made of RN A performing IV administration of Lasix to the Right antecubital area (the inside crook of the elbow). In the middle of the procedure while the catheter was still inserted in the antecubital of the arm, RN A Removed his gloves he stated to “better feel for the vein”. The catheter must be inserted into the vein to administer the medication. This was the first attempt to access the Vien however after some manipulation of the butterfly catheter, RN A removed the Catheter from the arm and placed a cotton ball at the catheter insertion site with noted blood droplets at the insertion site; all without gloves to RN A’s hands. In an interview on 04/17/25 at 11:15 a.m., RN A stated he removed his gloves in the middle of the procedure because the vein moved, and he could not feel the vein with his gloves on. He stated that he put himself and the patient at risk for infection and bloodborne pathogen infection. Record review of patient #3’s electronic medical record included a “Home Health Certification and Plan of Care” (POC) initiated on 02/18/25 that documented a start of care date of 08/22/25 and a certification period of 02/18/25 through 04/18/25. Furthermore, the POC documented a principal diagnosis of Encounter for fitting and adjustment of urinary device. The POC documented the following orders for disciplines and treatment: Skilled Nursing once a week for 9 weeks SN to perform Skilled head to toe assessment Q (every) visit using standard precautions. Foley insertion site care to be performed as follows: using aseptic technique and sterile supplies, wash insertion site with soap and water, pat dry with dry gauze, apply drain sponge to insertions site daily and PRN soiled area. SN may perform during scheduled visit for assessment of insertion site and report any abnormal findings to Medical Doctor. Foley Change to be performed as follows: using sterile technique and sterile supplies to change indwelling urinary catheter using a 16 French with a 10-milliliter balloon weekly and or as needed for dislodgement leakage or blockage. During a Home Visit with Patient #3 on 04/17/2025 at11:30 a.m. an observation was made of RN A performing a Sterile suprapubic Foley Catheter Change. During the procedure RN A was preparing his sterile field (A sterile field is a designated area which is free of microbes and other pathogens that can infect someone. The sterile field can include surfaces, instruments, and people. Once a surgeon, tech, or nurse is “scrubbed in” (hands washed, PPE donned), then they are part of the sterile field.) RN A had not yet placed sterile gloves on his hands. Upon opening the sterile package containing the new Foley catheter and materials needed RN A placed the Blue sterile sheet on the bed then touched the inside of the sterile field with his nonsterile hands, which had contaminated the sterile field, then placed his sterile gloves on his hands, which due to the contamination were no longer sterile. RN A continued with the Procedure, removed the old Foley catheter, then turned around, which fully contaminated the rest of the materials and reached for a non-sterile bottle of hand sanitizer and placed it on the place where the sterile field further containing the space and used the hand sanitizer on the sterile gloves.[AE3] RN A continued to Place the Sterile Foley catheter in the Patient s suprapubic opening. RN A completed Procedure and disposed of the old supplies. During an Interview on 04/17/2025 at 12:30 PM, RN A Stated that he did not realize that he touched the initial Sterile field with his hands or that he reached for and used the Hand sanitizer. Nurse Surveyor asked if during a sterile procedure were [AE4] you supposed to turn you back on a sterile field He stated “no”, Nurse Surveyor then asked if he was able to use hand sanitizer on sterile gloves in the middle of a procedure, he again stated “no, that will break/ Contaminated the sterile field.” Nurse surveyor then asked, “how can this harm the Patient”, RN A stated that “this can cause infection. During an Interview on 4/22/2025 at 4:30pm with the Administrator, Alternate administrator/ DON, and RN A/ Alternate DON. Director Of Nurses stated that they follow The CDC and OSHA Guideline for infection control and sterile procedures. The DON stated the incidents were an infection control and safety issue. The DON stated the Agency used CDC and OSHA guidelines for infection control. DON Stated that she used Lippincott (a leading international medical publisher of professional health information for practitioners, faculty, residents, students, and healthcare institutions as reference for education in training the nurses for Procedures.) The DON stated this was a potential exposure for risk infection and bloodborne pathogens. The DON stated it was her responsibility to in-service nurses and staff on infection control[AE5] She stated that all the nurses have yearly Infection control training and go to Laredo Medical center for in-services on Different procedures and protocols when available. The DON stated the Agency followed OSHA guidelines for infection control. The DON stated the incident was not appropriate and did not follow infection control measures by Agency. The DON stated the nurse should have not removed his gloves during the procedure. The DON stated the potential negative effects of this was a risk of infection for staff and other patients. The DON stated the Agency and RN A did not follow Agency policies regarding infection control and safety. [AE6] The DON stated that according to the POC, RN A should have followed aseptic technique and washed his hands for 20 seconds. The DON stated RN A also failed to follow Agency policies regarding infection control and safety because of procedure that was used in regard to the administration of Iv Medication. The DON stated it was her responsibility to ensure Agency policies regarding infection control and safety policies were implemented. The DON stated not implementing infection control or safety policies could negatively affect patients because staff could injure patients or cause infection. The[AE7] DON stated Agency staff get in-serviced at least once a year on infection control and safety precautions by the director of nurses. Last in-service was 01/03/2025 in which RN A did attend.[AE8] Review of RN A’s personnel File revealed a nurse competency Check list dated 11/25/2020 Performance Evaluation dated 12/20/2024 stated that RN A Provides patient / Patient and caregiver education, provides care using infection control measures that protect staff and patient /Patient Participate in Agency – sponsored in-service training, All with a score of 4 (4= Meets and occasionally exceeds job requirement). Record review of Agency policy titled, “Blood Collection”, with revised date noted 05/01/2006, quoted in part, “[All staff]” Performing a collection of Blood, will wear gloves…” Record review of Agency policy titled, “Infection Control Program”, with revised date noted 07/01/2021, quoted in part, “[Agency]” Infection Control program will be based in 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 Blood borne Pathogens… C.3 Other policies to be followed by the staff to prevent, control, and improve Infections include but not limited to Hand Hygiene, Cleaning and Management of Supplies and Equipment and disposal of needles and sharps policy… Education, A. Employees Upon hire and annually thereafter all agency employees will be educated regarding the policies and procedures related to Infection control, Bloodborne /Airborne/ HIV Pathogen Program, Patient/ Patient care procedures for preventing and /or controlling infections and standard precautions. Review of OSHA 29 CFR 1910.1030, titled Bloodborne pathogens, accessed 02/27/25, quoted in part, “Occupational Exposure means reasonably anticipated skin, eye mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties… Parenteral means piercing mucous membranes or the skin barrier through such events as needlesticks, human bites, cuts, and abrasions…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)(1) General. Universal precautions shall be observed to prevent contact with blood or other potentially infectious materials. Under circumstances in which differentiation between body fluid types is difficult or impossible, all body fluids shall be considered potentially infectious materials…(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…. (2)(vii)(B) Such bending, recapping or needle removal must be accomplished through the use of a mechanical device or a one-handed technique… (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… (d)(4)(iii)(A)(1) Contaminated sharps shall be discarded immediately or as soon as feasible in containers that are… (d)(4)(iii)(A)(1)(i) Closable…(d)(4)(iii)(A)(1)(ii) Puncture resistant… (d)(4)(iii)(A)(1)(iii) Leakproof on sides and bottom; and… (d)(4)(iii)(A)(1)(iv) Labeled or color-coded in accordance with paragraph (g)(1)(i) of this standard.” Record review of Lippincott Advisor and Lippincott Procedures titled, “Standard Precautions, home care”, with a revised date 08/18/24, 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 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 organisms…Wear gloves if you may or will come into contact with blood, specimens, tissue, body fluids, secretions, excretions, mucous membranes, broken skin, or contaminated surfaces or objects… Handle used needles and other sharps carefully. Don’t bend, clip, recap, or otherwise manipulate them. Activate any safety mechanisms, such as a retraction feature on a syringe or lancet and a hinged or sliding shield on a needle, immediately after use… Discard the sharps immediately after use into a puncture-resistant sharps disposal container. Never force a sharp into a container or put your fingers into the container. Never place used sharps in regular household trash, recycling bins, or plastic biohazard bags… Record review of Lippincott Advisor and Lippincott Procedures titled, Suprapubic Catheter replacement, with a revised date 11/17/24, quoted in part, with a revised date 08/18/24, quoted in part… Drape the catheter insertion site using sterile technique. Insert 5 to 10 mL of sterile water-soluble lubricant into the tract created by the suprapubic catheter to facilitate insertion of the new catheter. Instruct the patient to take deep breaths and to relax the abdominal muscles (if able) during catheter insertion to ease insertion. Insert the new catheter into the suprapubic tract and, when urine begins to flow, advance the catheter about 2” (5 cm) farther to ensure that the catheter is in the patient’s bladder. Inflate the balloon of the catheter using a 10-mL syringe filled with sterile water to prevent catheter dislodgment. Check the manufacturer’s instructions for the volume required. Record review of Lippincott Advisor and Lippincott Procedures titled, Sterile Technique, basic, Home care, with a revised date 05/19/24, quoted in part, … Clean technique requires using such strategies as performing hand hygiene, wearing clean gloves, using clean supplies and sterile instruments and ensuring that they don’t become contaminated, and maintaining a clean environment to reduce the number of microorganisms that may be transferred to the patient. Sterile technique involves the use of such strategies as modifying the environment, performing hand hygiene, wearing sterile gloves, applying other physical barriers, maintaining a sterile field, using only sterile instruments and supplies and, for some procedures, cleaning the patient’s skin using an antiseptic to eliminate microorganisms that may be transferred to the patient… Sterile technique is required whenever a patient’s skin is intentionally perforated, during procedures that involve entry into a sterile body cavity, and when contact with nonintact skin is possible as a result of trauma or surgery. Procedures that require sterile technique in the home include preparation of total parenteral nutrition and chemotherapeutic agents, vascular access insertion and care, and indwelling urinary catheter insertion and care. Other procedures, such as intermittent urinary catheterization, tracheostomy care, and wound care, may also require sterile technique depending on the patient’s condition and agency protocols. In addition, because of their increased susceptibility to infection, patients with compromised immune systems may require sterile technique for some procedures that would typically require only clean technique. When preparing a sterile field and during a sterile procedure, always face the sterile field because objects out of your visual field may become contaminated without your knowledge. Keep your hands above the level of the sterile field.Opening sterile kits Remove the plastic outer wrapper from the procedure kit, if present.Place the inner wrapped kit in the center of the work surface.Position the inner wrapped kit with the tip of the triangle-pointed wrapper pointing toward you, allowing you to open the farthest wrapper flap first because doing so prevents contamination that may occur from moving your unsterile arm over the sterile items.Grasp the outer portion of the wrapper flap (no more than 1” [2.5 cm] of the edge) and open the flap away from your body, keeping your arm outstretched to the side so that it doesn’t cross over the sterile field.Grasp the outer surface of the first side wrapper flap with your hand on the same side as the flap to avoid crossing over the sterile field. Be sure to open the flap fully to avoid allowing the wrapper to spring back into place.Grasp the outer surface of the second side wrapper flap with your hand on the same side as the flap. Open that flap.Grasp the outer surface of the innermost wrapper flap and open it toward your body.Secure the wrapper edges to prevent them from contaminating sterile areas and items.Preparing a sterile field using a sterile drape Open the outer wrapper containing the sterile drape.Using both hands, pinch over the top edge (1” [2.5 cm]) of the two corners, touching only the moisture-proof underside (shiny or blue side) of the sterile drape to avoid contaminating the sterile side of the drape.Carefully remove the sterile drape from the outer wrapper so that the sterile side is facing away from you. Keep the sterile drape away from your body and above the work surface.Allow the sterile drape to unfold. Don’t allow it to come in contact with your body or any other object to avoid contamination.Position the sterile drape on the work surface with the moisture-proof underside down on the work surface. If any part of the sterile drape hangs over the side of the work surface, consider that area contaminated.Adding sterile items in peel-pack containers or pouches to the sterile field Open peel-pack containers or pouches by grasping each side of the unsealed edge with the thumb side of each hand parallel to the seal and gently pulling the sides apart.Hold back the sides of the container or pouch so that the wrap covers your hands and exposes the sterile item.Holding the sterile item 6” to 8” (15 to 20 cm) above the work surface, drop it onto the sterile field, avoiding the 1” (2.5-cm) margin around the edge of the sterile field. Don’t allow the sterile item to slide across the container or pouch sides when you drop the item onto the sterile field. Holding the sterile item too high may cause it to fall outside the sterile area; holding it too low may cause your hand to contaminate the sterile field.The agency did not dispute the survey findings and did not provide this surveyor with any additional requested documents upon exit”