Federal records show prior lapses at Live Oak health center

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Infection-control errors noted in HHS inspection reports on Suwannee Health.

  • Suwannee Health and Rehabilitation Center, the common factor in a cluster of covid-19 deaths in Suwannee County, has previously been told to shore up its safeguards against disease, according to inspection records from the U.S. Department of Health and Human Services.
    Suwannee Health and Rehabilitation Center, the common factor in a cluster of covid-19 deaths in Suwannee County, has previously been told to shore up its safeguards against disease, according to inspection records from the U.S. Department of Health and Human Services.
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The epicenter of a covid-19 outbreak in Live Oak has a history of infection-control issues, according to records from federal health officials. 

Suwannee Health and Rehabilitation Center, the common factor in a cluster of covid-19 deaths in Suwannee County, has previously been told to shore up its safeguards against disease, according to inspection records from the U.S. Department of Health and Human Services. In an eight-month timespan between June 2017 and February 2018, inspectors uncovered a range of problems that included unhygienic wound care and failing to follow precautions around a particularly vulnerable resident, according to reports. 

Suwannee County’s covid-19 death toll was at 18 as of Friday. All of those were residents at the nursing home, according to data on the Florida Department of Health website. 

There were 151 cases total in Suwannee County, the latest data available showed. It’s not clear how many are linked to Suwannee Health and Rehabilitation Center. State health officials have not given comprehensive data on the number of covid-19 cases in Florida’s nursing homes. 

The Florida Department of Health has provided some numbers but they are not cumulative and represent only a snapshot in time. 

A report for May 1 indicates Suwannee Health and Rehabilitation Center had 31 residents who tested positive for the virus, not including an additional 33 who were transferred out of the facility’s care, and 19 infected staffers. As of May 14, however, health officials were reporting 28 cases among current residents, 34 among transferred residents and four among staffers. 

Prior issues

Following a June 2017 inspection, the U.S. Department of Health and Human Services told Suwannee Health and Rehabilitation Center to implement a program that investigates, controls and prevents infections from spreading. Federal health officials again issued the same demand in February 2018 after two follow-up visits. 

The February 2018 inspection revolved around concerns over a resident placed in medical isolation. 

Staff and visitors needed to wear personal protective equipment while in the resident’s room, according to the inspection report. 

But during the morning of Feb. 19, a certified nursing assistant was seen moving the resident’s blue blanket off a bedside table without gloves or other protective gear, the report says. 

The male nurse touched the blanket to his uniform before placing it on the resident’s bed, according to the report. 

The nurse admitted to being unsure whether the resident was still under isolation protocols, the report says. 

Later in the afternoon, a different nurse admitted to not informing the resident’s family they were required to wear protective gear in the room, according to the report. 

The confession came after two visitors were seen in the room, neither of whom were wearing protective gear, the report says. 

An inspector questioned one of the visitors, the resident’s son, who said the facility didn’t inform him of the protocols, according to the report. 

“This is the first time I have seen anyone wearing gloves or gowns,” the son reportedly told inspectors. 

Federal health officials demanded more stringent procedures to safeguard residents against infection, specifically infections involving microorganisms capable of being transmitted through both direct contact and indirectly through exposure to surfaces. 

In June 2017, inspectors cited the nursing home for violations that included unhygienic wound care. 

On the afternoon of June 20, 2017, a licensed practical nurse was with a resident who had a stage four pressure ulcer on the sacrum and a stage three ulcer on the right hip. 

The nurse had washed her hands and put on clean gloves before cleaning out the hip ulcer. After finishing that step, she was supposed to wash her hands again and change into a new pair of gloves before moving on to the next part of the process.

She didn’t do that, according to the inspection report. 

The nurse cleansed the wound with saline on a gauze and wiped down the surrounding tissue, failing to wash her hands or change into sterile gloves before applying a dry dressing, the report says. 

The nurse repeated her error while dealing with the second ulcer, according to the report. 

In an interview later that day, the nurse confirmed she ran afoul of protocols, which stipulates that staff wash hands and equip themselves with a fresh, sterile pair of gloves between cleaning and dressing a wound, the report says. 

The day prior to that visit, inspectors also witnessed a kitchen staffer ignoring a hand-washing station before retrieving clean dishes and discovered an “unusually humid and wet” room with a broken shower head and pooling water, posing a bacterial infection risk, according to the report. 

During a Nov. 2, 2017, visit, inspectors concluded that the “facility failed to provide proper infection control techniques” while providing catheter care to one resident. 

A certified nursing assistant soaked a clean washcloth in a basin of soapy water and wiped the left side of the resident’s genital area using a downward stroke, according to the report. 

The nurse then used the same wash cloth to wipe the catheter tube near the insertion site, cross-contaminating the equipment with bacteria, the report says. 

The facility’s director of nursing, in an interview later that afternoon, agreed that the nurse should have changed the washcloth or at least used a different area of the rag when wiping the catheter tube, according to the report. 

Multiple attempts were made to have the administration at Suwannee Health and Rehabilitation Center provide greater context for the issues listed in the inspection reports. The facility did not return repeated calls seeking comment.