Every finding on record at South Peninsula Hospital Inc

An Emergency Preparedness Survey was conducted by the State of Alaska Department of Health and Social Services in accordance with 42 CFR 484.102. Provider #: 027010 Facility ID: HHA-013 Visit dates: 11/2/21 - 11/5/21 Skilled Unduplicated Census past 12 months: 153 Patients At this Emergency Preparedness survey, South Peninsula Hospital Home Health was found to be in compliance with 42 CFR 484.102, Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers.

This visit was for Federal Recertification and State Licensure Survey. This survey was partially extended. Provider #: 027010 Facility ID: HHA-013 Visit dates: 11/2/21 - 11/5/21 Skilled Unduplicated Census past 12 months: 153 Patients 3 home visits were conducted. 2 visits were to observe skilled nursing home visits and 1 visit was to observe an occupational therapy home visit.

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 observation, interview and policy review, the agency failed to ensure infection control practices were properly implemented at 1 of 2 home visits observed with a skilled nurse (Patient #2 with Licensed Nurse #1). Specifically, the agency failed to ensure the skilled nurse removed gloves prior to performing hand hygiene and removed gloves after the skilled nurse's gloves were soiled. This failed practice had the potential to place the patient at risk of transmission of pathogens and exposure to infectious organisms. Findings: During an observation on 11/3/21 at 8:05 AM, Licensed Nurse (LN) # 1 was observed to complete an intravenous (IV) start and infusion procedure with Patient #2. At this visit, LN #1 was observed to don clean gloves and then proceed to attempt to flush the IV site at the patient's right wrist and then LN # 1 stated the site was plugged off and had light redness in the site area. LN # 1 attempted to start an IV at the left wrist with no success. After this unsuccessful attempt, LN #1 cleansed his / her gloves with hand sanitizer and then proceeded to start another IV at the patient's right antecubital space (inner or front surface of the forearm). This was successful. LN # 1 then cleansed his / her gloves with hand sanitizer and then removed the IV needle and dressing at the right wrist area with the same gloves on, applied a new dressing, and had the patient apply pressure at this site. LN # 1 picked up the discarded supplies and then discarded these with the same gloves still on. LN # 1 discarded the needle into a sharps container. LN # 1 attached the IV tubing and solution to the IV needle in the right arm so the IV fluid would flow into the patient's arm. The nurse then sanitized his / her gloved hands and wrote notes onto the laptop computer. LN # 1 listened to the patient's lung and heart sounds with a stethoscope and asked the patient questions about his / her symptoms including dizziness, memory, depression, sleeping status, future appointments, medication changes, urinary and bowel status. At this time, LN # 1 went to the car to get more supplies with the same gloves on and then returned to the house. At this time, LN # 1 took off his / her gloves and sanitized hands with hand gel before applying clean gloves. He / she proceeded to discontinue the IV after its completion and removed the IV needle with the patient applying pressure to the site with his / her fingers resting on a gauze pad. LN # 1 discarded those supplies and then returned with the same gloves on and took the patient's vital signs including blood pressure and heart rate. LN # 1 packed up the supplies and then took the gloves off and washed hands with sanitizer. During an interview on 11/4/21 at 9:40 AM, LN #1, when questioned about sanitizing gloves with hand sanitizer gel, stated that this was an automatic habit. LN #1 stated that he / she tries to save on glove use. LN # 1 stated, "I am very conscious of keeping everything clean." He / she stated, "I sanitize before taking the soiled dressing off." He / she also stated, "You don't always have supplies and water readily available in the home. I wash my hands a lot." LN # 1 stated that he / she always used a brand new pair [of gloves] when starting an IV." During an interview on 11/4/21 at 10:40 AM, the Administrator stated, when questioned about sanitizing gloves with hand sanitizer instead of removing the gloves after use, that "this is not what we teach or what we want." A review of the policy / procedure on 11/4/21 at 11 AM titled "Standard Precautions, Home Care" reviewed 8/19/21 stated, "The Centers for Disease Control [CDC] developed standard precautions to protect against the transmission of infection … Implementation … Perform hand hygiene before and after patient care; before putting on and after removing gloves … if your hands aren't visibly soiled, use an alcohol - based hand rub for routine hand hygiene …. 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." A review of the policy / procedure on 11/4/21 at 11 AM titled "Personal Protective Equipment [PPE] putting on, home care" reviewed 8/19/21 stated, "Improper PPE can lead to pathogen transmission and exposure to infectious organisms."