South Lyon Medical Center
SOUTH LYON MEDICAL CENTER in YERINGTON, NV — inspection on July 23, 2024.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
The facility policy titled Quality Management Program, last revised 11/2017, documented the QAPI committee, with the support and approval of the Governing Body, had the responsibility for monitoring every aspect of resident care and service from the time the resident entered the facility, through diagnosis, treatment, recovery, and discharge in order to identify and resolve any breakdowns with the potential to result in sub-optimal resident care and safety, while striving to continuously improve and facilitate positive resident outcomes.
295011
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 295011 B.
Wing 07/23/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
South Lyon Medical Center 213 Whitacre St Yerington, NV 89447
295011
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 295011 B.
Wing 07/23/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
South Lyon Medical Center 213 Whitacre St Yerington, NV 89447
Infection Control and Prevention Plan Policy
The facility's IPCP policy documented the policy was last reviewed by the facility on 10/2022.
The facility was not able to provide evidence the policy had been reviewed and/or revised after 10/2022.
The policy referred to IPCP as the hospital's IPCP and the referenced duties for hospital staff did not include language indicating the policy included the Long-Term Care facility.
The IPCP lacked the following elements:
-a list of reportable communicable diseases and a process for reporting to the appropriate state agencies.
-prohibition of employees with communicable diseases or infected skin lesions from direct contact with residents or their food if direct contact could transmit disease.
-a process for communicating at time of a transfer to another care provider, to include diagnoses, infections, multi-drug resistant organisms (MDRO)status, special instructions or precautions including transmission-based precautions (TBP), medications, lab work, other diagnostics, test results, treatments, and discharge summary if applicable.
-a process to ensure receipt of pertinent notes when transferred back from an acute care hospital or other facility type.
The IPCP policy referenced an additional policy titled List of Nationally Notifiable Diseases, last revised 06/2020.
The policy did not list the reportable diseases but provided two links to the most current nationally notifiable diseases.
The links were dated 2020 and neither of the links were active. At the bottom of the policy, under references, an active link was provided.
The policy did not include guidance for prohibition of employees with communicable diseases or a process for reporting to the appropriate agencies.
295011
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 295011 B.
Wing 07/23/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
South Lyon Medical Center 213 Whitacre St Yerington, NV 89447
Communication with Prescribing Providers
On 07/18/2024 at 10:12 AM, the IP never communicated with physicians/providers and explained the IP was not clinical.
295011
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 295011 B.
Wing 07/23/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
South Lyon Medical Center 213 Whitacre St Yerington, NV 89447
F-F887), and 5) the IP communicated with providers regarding prescribing trends, needs, and outcomes, with the potential to effect the facility's entire census of 27 residents.
Findings include:
Specialized Training
A facility document titled Payroll Status Form, dated 10/13/2022, documented the facility's IP had a hire and status (role) date of 10/13/2022.
The role was documented as Infection Preventionist.
On 07/16/2024 at 7:39 AM, the IP verbalized the IP had completed the Centers for Disease Control and Prevention (CDC) Infection Preventionist Training Course and provided a certificate documenting the IP had participated in an educational activity and was awarded two Continuing Education Units (CEUs).
The certificate did not document the 19.75 CEU hours required for course completion.
The IP provided a copy of the IP's Nursing Home Infection Preventionist Training Course transcript.
The transcript documented the IP had completed 15 of the IP training course modules and one course was still required.
The section of the transcript titled Completion for Nursing Home Infection Preventionist Training Course, was marked as not started.
The IP confirmed the IP did not have any further documented evidence of course completion.
On 07/16/2024 at 3:11 PM, the Director of Nursing (DON) confirmed the Infection Preventionist Training Course Transcript provided by the IP lacked documented evidence the IP had completed the IP training course.
The DON verbalized the IP training course needed to be completed prior to an individual assuming the role of IP and confirmed the IP had been working in the role of IP without having completed an approved IP specialized training course.
A facility document titled Infection Control Preventionist - Job Description, signed and dated by the IP on 04/04/2022, documented the IP was required to have knowledge of state and federal regulations regarding infection control.
The Job Description failed to address the requirements related to the completion of specialized training in infection control.
Antibiotic Stewardship Education
On 07/18/2024 at 9:12 AM, the facility was not able to provide documented evidence the facility provided education related to the ASP to the facility's staff.
The DON confirmed the facility did not have documented evidence education related to the ASP was provided to staff and confirmed the education was not provided.
295011
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 295011 B.
Wing 07/23/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
South Lyon Medical Center 213 Whitacre St Yerington, NV 89447