Sevierville Health And Rehabilitation Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow infection prevention and control practices during wound care and resident care activities for multiple residents. Resident #57, who had diabetes, heart failure, and a stage 3 sacral pressure ulcer, was observed receiving wound care while a sign for Enhanced Barrier Precautions was posted on the door. The LPN sanitized hands and donned gloves, but did not don a gown, changed gloves without performing hand hygiene, cleaned the wound with saline-soaked gauze using strokes from proximal to distal rather than in a circular motion from the inside out, and changed gloves again without hand hygiene before applying medication and dressing. The DON confirmed that wound cleaning should be done in a circular motion from the inside to the outside and that hand hygiene should be performed each time gloves are discarded. The facility also failed to properly store or label toileting and oral care items in shared bathrooms. In the bathroom used by Resident #54, who had dementia, stroke history, and generalized weakness and was incontinent and dependent for toileting hygiene, a bedpan was observed placed between a grab bar and the wall without a barrier. In the shared bathroom of Residents #81 and #9, toothbrushes were observed on the back of the toilet and on the sink, both unlabeled and uncovered. Resident #81 had diabetes, adult failure to thrive, and generalized weakness and was dependent for transfers and oral hygiene, while Resident #9 had dementia, peripheral vascular disease, and muscle weakness and required supervision for transfers and assistance with oral hygiene. Additional observations showed unlabeled and uncovered denture brushes in the shared bathroom of Residents #71 and #30, and an unlabeled bedpan hanging in a clear bag on a grab bar in the shared bathroom of Residents #59 and #72. Resident #71 had diabetes, heart failure, generalized weakness, and broken or loosely fitting dentures and required assistance with oral hygiene; Resident #30 had dementia, type 2 diabetes, and generalized weakness and was dependent for transfers and oral hygiene; Resident #59 had subdural hemorrhage, diabetes, and weakness and was frequently incontinent; and Resident #72 had dementia, hypothyroidism, and generalized weakness and was always incontinent and dependent for transfers and toileting hygiene. CNA staff stated bedpans and toothbrushes should be labeled and stored in containers or bags, and the ADON and DON confirmed that the unlabeled and improperly stored items did not follow appropriate infection control practices.