HospitalInspections.org

Based on observation, interview, record review, and policy review, the hospital failed to:
- Implement and document seizure precautions (precautions designed to protect a patient from injury and to reduce stimuli that may trigger the onset of a seizure) for one current patient (#9) out of one reviewed;
- Prevent and manage wounds appropriately for four current patients (#4, #25, #27, and #40) of eleven reviewed, and one discharged patient (#51) of one reviewed;
- Adequately document assessments for five current patients (#2, #3, #4, #22, and #40) of eleven reviewed, and three discharged patients (#49, #50 and #51) of four reviewed; and
- Ensure staff followed intravenous (IV, in the vein) medication administration guidance for two current patients (#27 and #45) of six patients observed.

These failures had the potential to lead to poor outcomes, increased risk of harm, impaired skin integrity, and overall increased risk of health status deterioration for every patient admitted to the hospital.

Based on observation, interview, record review, and policy review, the hospital failed to:
- Implement and document seizure precautions (precautions designed to protect a patient from injury and to reduce stimuli that may trigger the onset of a seizure) for one current patient (#9) out of one reviewed;
- Prevent and manage wounds appropriately for four current patients (#4, #25, #27, and #40) of eleven reviewed, and one discharged patient (#51) of one reviewed; and
- Adequately document assessments for five current patients (#2, #3, #4, #22, and #40) of eleven reviewed, and three discharged patients (#49, #50 and #51) of four reviewed.
These failures had the potential to lead to poor outcomes, increased risk of harm, impaired skin integrity, and overall increased risk of health status deterioration for every patient admitted to the hospital.

Review of the hospital's undated document titled, "Initiating Seizure Precautions for Adults," showed staff were to implement the following for patients with seizure (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness) related concerns:
- Review the patient's care plan, physician orders, and hospital policy for initiating and maintaining seizure precautions.
- Review the patient's medical history/medical record for indications for seizure precautions, relevant medical history, including the type of previous seizures, medications, pertinent laboratory values that could indicate potential for seizures, such as electrolyte imbalances, and any allergies the patient may have.
- Ensure interventions such as padding around the headboard, foot board and side rails, the bed in the lowest position and signage has been placed, if the patient was at risk for seizures.

Review of Patient #9's medical record showed:
- On 12/01/24, a 61-year-old woman with a past medical history of a seizure disorder was admitted to the medical-surgical unit after a fall.
- On 12/01/2024 at 5:43 PM, seizure precautions were ordered.
- On 12/03/24 at 1:04 PM, seizure precautions were discontinued upon patient's transfer from the operating room (OR).

Observation on 12/02/24 at 4:00 PM, showed Patient #9 was in a hospital bed with unpadded headboard, footboard, and side rails.

Observation on 12/03/24 at 8:49 AM, showed Patient #9 was in a hospital bed with unpadded headboard, footboard, and side rails.

During an interview on 12/02/24 at 4:00 PM, Staff K, RN, stated that patients on seizure precautions should have the hospital bed side rails padded. She had not had time to place the padding on Patient #9's side rails during her shift.

During an interview on 12/03/24 at 8:15 AM, Staff Q, Medical-Surgical Manager, stated that she expected seizure precautions to begin within one hour of admission for patients with known seizure history.

Review of the hospital's policy titled, "Prevention of Pressure Injuries (injury to the skin and/or underlying tissue, usually over a bony area)," dated 02/28/23, showed:
- Pressure injuries were categorized into the following stages: stage one pressure injury was a non-blanchable erythema (redness of the skin) of intact skin; stage two was a partial-thickness skin loss with exposed dermis (middle layer of skin); stage three was a full-thickness skin loss; stage four was a full-thickness skin and tissue loss; unstageable pressure injuries were obscured, full-thickness skin and tissue loss; and deep tissue pressure injuries were persistent, non-blanchable deep red, maroon, or purple discoloration.
- All patients would have a full skin assessment and be assessed for pressure injury risk level using a standardized, evidence-based, risk assessment tool upon admission, once per shift, following any change in medical condition and upon transfer. A score less than or equal to 18 was considered "at risk."
- The hospital's skin risk assessment tool was modified from the Braden Scale (an assessment tool for predicting the risk of bedsores or pressure ulcers).
- Patients who were determined to be not at risk would have ongoing skin assessments with their complete patient assessments. Patients found to be at-risk would have focused skin assessments every four hours or more frequently if ordered by a licensed practitioner.
- Pressure injury interventions and an individualized plan of care, including education, would be implemented and documented for all at-risk patients.

Review of the hospital's policy titled, "Wound Assessment & Treatment (Non pressure ulcers)," dated 01/21/19, showed staff were to notify the wound nurse and physician for lower extremity and foot wounds for consultation prior to utilizing specific products, if there was deterioration of wounds, signs of wound or systemic infection, or a poor response to therapy. Patients and families were to be educated about the importance of high protein/carbohydrate foods and fluids to promote wound healing, the need to inspect skin daily, to keep the skin clean and dry and the use of available skin products.

Review of the hospital's policy titled, "Nursing Departments Standards of Care," dated 05/2023, showed patients would be bathed with 2% chlorhexidine gluconate (CHG, a disinfectant and antiseptic used to bathe patients in order to kill bacteria and reduce the spread of infections) wipes on admission and daily. Perineal/perianal area would be cleansed and skin barriers applied as needed. Patients would be encouraged to walk or sit up in a chair as much as tolerated and per the physician orders. Patients on bedrest would be turned and repositioned every two hours and as needed. Skin integrity was assessed on admission, at each shift, and as needed. Universal skin care practices were used for all patients. Bony prominences were monitored and precautions would be taken to prevent pressure areas.

Review of Patient #4's medical record showed:
- No skin assessment was documented on admission.
- On 11/19/24, a nursing assessment noted he had a deep tissue injury on the tailbone. There was no wound description or measurement documented.
- On 11/21/24, an orders for a wound consult and daily ointment were placed.
- On 11/22/24, Staff V, Wound Nurse, described the wound as beefy red with slough present. He applied a dressing, but no wound measurements or staging for severity was documented.
- On 11/25/24, 11/26/24, and 11/29/24, no wound care was documented.
- Patient #4's skin assessment rating scores were consistently below 18, indicating he was at risk for developing a pressure wound.

Observation on 12/03/24 at 8:30 AM, showed Patient #4 had an open wound with a large area of redness. Staff Y, RN, provided wound care but failed to take any wound measurements at the time of the dressing change.

During an interview on 12/03/24 at 8:30 AM, Patient #4 stated that he did not remember when his wound developed. He was only turned and repositioned by staff twice daily when they checked him for bowel movements.

Observation and concurrent interview on 12/03/24 at 10:00 AM, showed Staff V, Wound Nurse, failed to place a clean barrier under Patient #25's leg during a wound dressing change. He failed to use a barrier when assembling wound dressing supplies, placing them directly on the countertop adjacent to the sink. He stated he did not place a barrier under Patient #25's leg during the dressing change as the wound was not "oozing."

Observation on 12/03/24 at 1:30 PM, showed Staff V, Wound Nurse, performed a dressing change and pressure injury assessment on Patient #27's tailbone area. When the patient was turned, he was found to have soiled himself. Staff V removed the old dressing and cleaned the patient of incontinence. He then removed his gloves and donned new gloves without performing hand hygiene. The wound was not cleansed with saline or any other product. He then applied a new foam dressing and dated it.

During an interview on 12/03/24 at 1:45 PM, Staff V, Wound Nurse, stated that Patient #27 did not have any physician orders specifying the wound treatment. It was usual practice for him to be consulted by the physician or nurse and for him to make recommendations on the wound treatment products and interventions. He demonstrated how he placed orders after his assessment and stated the physicians always sign them off. He stated he usually cleans wounds with saline or another wound cleansing product depending on the wound.

Review of Patient #40's medical record showed:
- On 11/15/24, she was admitted for dizziness, confusion, weakness and frequent falls.
- Her initial skin assessments showed no alterations other than a contusion to her face.
- She had a history of diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing), neuropathy (develops when nerves in the hands, feet or arms, are damaged), chronic kidney disease (CKD, ongoing, gradual loss of kidney function) and left leg arterial occlusions.
- On 11/18/24, she was noted to have swelling to her left lower leg by PT.
- On 11/22/24, an x-ray (test that creates pictures of the structures inside the body-particularly bones) was obtained of her left foot. Her morning assessment did not indicate any concerns related to that extremity. The afternoon reassessment indicated dark red discoloration or bruising. The foot wound was warm and closed, without any drainage. A dressing was applied.
- On 11/22/24, she was discharged. The discharging physician did not reference a foot wound and her case management notes only addressed her dialysis (process that removes excess water and toxins from the blood when the kidneys can no longer perform these functions) needs.
- On 12/04/24, she patient was readmitted for surgery related to gangrenous (localized death of tissue resulting from either obstructed blood flow or infection) tissue and to have her 4th and 5th toes, on the left foot, amputated (removal of an injured or diseased body part).

During an interview on 12/03/24 at 2:52 PM, Patient #40's husband stated that during her hospitalization two weeks prior the staff neglected to notice wounds and discoloration that developed on her left foot. She was expected to go to surgery the next day to have toes amputated which could have been avoided if appropriate interventions had occurred sooner.

On 12/02/24 at 2:40 PM, a review of Patient #2's medical records showed inconsistent documentation of his skin and wound assessments. He was receiving ongoing treatment for wounds and the documented assessments failed to mention his wounds.

On 12/02/24 at 2:45 PM, a review of Patient #3's medical records showed inconsistent documentation of his skin and wound assessments. He was receiving ongoing treatment for wounds and the documented assessments failed to mention his wounds.

Review of Patient #22's medical record, dated 11/27/24 through 12/03/24, showed:
- She was a 74-year-old woman with a past medical history of multiple sclerosis (MS, a disorder in which the immune system attacks the protective covering of the nerve cells).
- She was admitted to the medical telemetry unit from home after 10 days of MS exacerbation (increase in symptoms) and generalized weakness.
- She was bed bound.
- At 4:00 AM, her skin risk assessment pressure injury risk score was 14. Her skin was warm and dry.
- At 9:00 AM, her skin was warm and dry.
- At 8:15 PM, her skin was warm and dry.
- On 11/28/24 at 9:00 AM, her skin was warm and dry.
- On 11/28/24 at 8:20 PM, her skin was warm and dry.
- On 11/29/24 at 9:00 AM, her skin was warm and dry.
- On 11/29/24 at 8:00 PM, her skin was warm and dry.
- On 11/30/24 at 1:54 AM, she was repositioned.
- At 8:00 AM, she was repositioned, six hours and six minutes later. Her skin was warm and dry.
- At 8:00 PM, her skin risk assessment pressure injury risk score was 13.
- On 12/01/24 at 5:03 AM, she was repositioned, 21 hours and three minutes later.
- At 7:45 AM, she was repositioned, two hours and 42 minutes later. Her skin was warm and dry.
- At 8:51 PM, she was repositioned, 13 hours and six minutes later. Her skin was warm and dry.
- On 12/02/24 at 9:55 AM, she was repositioned, 13 hours and four minutes later.
- At 11:07 AM, her skin was warm and dry.
- At 8:00 PM, her skin was warm and dry.
- On 12/03/24 at 8:30 AM, her skin was warm and dry.
- At 9:25 AM, she was repositioned, 23 hours and 30 minutes later.

Observation on 12/03/24 at 9:05 AM, Patient #22 was lying on a basic air mattress.

During an interview on 12/05/24 at 8:15 AM and at 9:38 AM, Staff S, CN, stated that Patient #22 was on a basic air mattress and "possibly had a waffle underneath her." Patients unable to turn themselves should be turned and repositioned every two hours.

Review of Patient #49's medical record showed:
- He was a 39-year-old man with cerebral palsy (CP, caused by abnormal brain development before birth, is a group of disorders that affect a person's ability to move and maintain balance and posture) and nonverbal.
- On 05/22/24 at 11:58 PM, he was admitted to the emergency department for low blood pressure from a group home.
- On 05/23/24 at 4:24 AM, he was admitted inpatient to the medical telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen) unit. Dressing changes were completed for a stage two anterior sacral pressure injury and a stage one posterior right sided buttock pressure injury, both present on admission.
- At 7:00 PM, he was repositioned.
- On 05/24/24 at 10:45 PM, bilateral contractures to his hands and legs were documented and positioning aids in place. He was bed bound and non-ambulatory (not able to walk) with generalized weakness.
- On 5/25/24 at 9:00 AM, he was repositioned. He had remained in the same position for 36 hours. He was placed on a low air loss specialty bed and required a two person assist.
- On 5/26/24 at 9:00 AM, he was repositioned. He had remained in same position for 24 hours.
- On 05/28/24 at 12:28 PM, nursing documented that a skin tear was present upon admission.

Review of Patient #50's medical record showed the following:
- She was admitted on 10/20/24 with no skin alterations or wounds.
- She had an initial skin risk score that suggested she was at risk for skin breakdown.
- Nursing documentation of the Skin Risk Assessment tool on admission was 14 indicating the patient was at risk for pressure injury (injury to the skin and/or underlying tissue, usually over a bony area).
- On 10/21/24 the nurse assessment showed the patient had a small area of redness measuring less than one centimeter (cm) with no depth or open areas, stating it was a Stage 1 pressure injury (intact skin with an area of redness that does not go away when pressure is applied) on her sacrum (triangular shaped bone above the tailbone). The wound was covered with a dressing. No orders were put into the chart for wound care.
- On 10/25/24, the wound was noted to be red with purple center. The dressing was changed with no measurements, description of wound, no plan of care update, and no provider notification was documented.
- On 10/26/24 and 10/27/24 the dressing was noted to be intact. There was no wound description noted.
- On 10/28/24 a dressing change was performed with no description of the dressing, no wound description, no wound measurements, no update to the plan of care, and no provider notification.
- On 10/30/24, dressing was noted intact, no documentation of wound measurements, description of wound, plan of care updates or provider notification.
- For 10/31/24 and 11/01/24 there was no wound or dressing assessment.
- Skin risk assessment tool rated Patient #50 a 17 at the time of discharge on 11/01/24 to a long-term acute care (LTAC, facilities that specialize in the treatment of patients with serious medical conditions that require care on an ongoing basis).

Review of Patient #51's medical record showed:
- On 04/22/24, he was admitted with no skin alterations or wounds.
- His initial skin risk score indicated he was not at risk for skin breakdown.
- Subsequent risk scores indicated his risk had increased over the course of his hospitalization.
- He was placed on a specialty low air loss mattress (LAL mattress, a pressure reducing mattress used to prevent and treat pressure ulcers) and had frequent hygiene interventions documented.
- On 05/23/24, a stage two pressure injury was noted and treated. Wound and Physical Therapy (PT, focuses on range of motion and decreasing pain after an injury or illness) consultations were ordered at that time.
- The patient was discharged to a long-term acute care (LTAC, facilities that specialize in the treatment of patients with serious medical conditions that require care on an ongoing basis) hospital the following day.

During an interview on 12/03/24 at 3:35 PM, Staff KKK, RN, stated that patients who were bed-bound were at risk for pressure injuries and were to be turned and repositioned every two hours. Skin assessments were to be completed every shift and turns were to be documented in the medical record.

During an interview on 12/05/24 at 12:20 PM, Staff B, CNO, stated that having only one wound care nurse for a hospital their size was probably insufficient and wound care was an opportunity for improvement. Her expectation was that a bedside nurse should be able to manage a stage one or stage two pressure injury and a wound consultation would be requested if the wound worsened. Nurses should turn immobile patients every two hours and assist patients who weren't entirely immobile as needed. She stated that she expected a patient with seizure precautions ordered would have those interventions implemented soon after admission. Clean barriers should be placed under the area of a patient's wound during dressing changes.


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Based on observation, interview and policy review, the hospital failed to ensure staff followed intravenous (IV, in the vein) medication administration guidance for two current patients (#27 and #45) of six patients observed. This had the potential to place all patients admitted to the hospital at risk for their safety.

Findings included:

Review of hospital's policy titled, "Administering a Subcutaneous Injection to Adults Procedure," showed:
-Nurses must create a general aseptic field by cleaning off and disinfecting the work surface (or tray). They should allow the surface dry before using, perform hand hygiene and apply gloves.
-If using a needle and syringe, nurses must cleanse the top of the vial with an antiseptic swab prior to inserting a filter needle, blunt tip needle or regular needle into the stopper of medication vial or ampule in order to withdraw the medication from the vial.
-After withdrawing the prescribed amount of medication, staff should detach the filter or blunt tip needle, dispose of it appropriately and attach a new needle to the syringe.

Review of the policy titled, "Medication Administration (MAR)," dated 07/2024, showed nurses are to review and acknowledge all medication orders prior to administration. Administrative or disciplinary action may be taken in situations of disregard for policy or for patient safety.

Observation on 12/04/24 at 8:45 AM, showed Staff Z, RN, failed to clean the rubber stopper of an IV medication, famotidine (a medication that treats excess stomach acid or heartburn), prior to the insertion of the needle for withdrawal, while administering medications to Patient #27. She then attempted to dilute an IV medication, piperacillin/tazobactam (an antibiotic), by injecting the medication to be diluted into the open needle hub of a syringe filled with normal saline, causing some of the medication to splash out of the open tip.

Observation on 12/04/24 at 8:30 AM, showed Staff WW, RN, failed to clean the rubber stopper of an IV medication, cephazolin (an antibiotic), prior to the insertion of the needle for withdrawal. She then administered the IV medication to Patient #45 in less than 30 seconds. The administration instructions for Cephazolin on the MAR indicated that the medication was to administered over three to five minutes.

During an interview on 12/03/24 at 2:10 PM, Staff Z, RN, stated she should have used a blunt tip to withdraw medication from the vial into the syringe with the normal saline.

During an interview on 12/03/24 Staff E, Vice President of Quality, (VPQ), stated she would expect nurses to clean the top of a vial prior to the withdrawal of medications.

During an interview on /12/05/24 with Staff B, Chief Nursing Officer, stated she expected nurses to follow administration instructions as indicated on the MAR and to follow hospital policies.

Based on observation, interview and policy review, the hospital failed to:
- Prepare a clean work surface prior to performing patient care for nine current patients (#4, #22, #23, #25, #27, #29, #31, #32, and #45) of 18 patients observed.
- Perform hand hygiene (HH, washing hands with soap and water or alcohol-based hand sanitizer) during patient care for five current patients (#23, #25, #27, #45 and #48) of 43 patients observed;
- Perform glove changes for three current patients (#4, #5 and#25) of 37 patients observed; and
- Ensure staff followed intravenous (IV, in the vein) medication administration guidance for two current patients (#27 and #45) of six patients observed.

Findings included:

Although requested, the hospital failed to provide a policies regarding the use of a clean work surface, use of barriers or glove changes while providing patient care.

Review of hospital's policy titled, "Hand Hygiene," dated 10/03/24, showed:
- The purpose of hand hygiene is to prevent the transmission of healthcare associated pathogens on the hands of healthcare personnel to reduce the incidence of healthcare-associated infections (HAIs).
- All healthcare personnel shall adhere to the Centers for Disease Control and Prevention (CDC, the nation's health protection agency that saves lives and protects people from health threats)
guidelines on hand hygiene as specified in this policy.
- Alcohol-based products and/or soap and water may be used for standard hand hygiene.
- Hand hygiene should be completed at the following instances: before and after direct contact with patients; before donning sterile gloves; before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices; after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient); after contact with body fluids, excretions, mucous membranes, nonintact skin, and during dressing changes; if moving from a contaminated-body site to a clean-body site during patient care; after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; or after removing gloves.

Review of hospital's undated policy titled, "Administering a Subcutaneous Injection to Adults Procedure," showed nurses must create a general aseptic (free from harmful bacteria, viruses, or other microorganisms) field by cleaning off and disinfecting working surfaces (or tray). Staff should allow the surface to dry before using, then perform hand hygiene and apply gloves. If using a needle and syringe, nurses must clean top of the vial with antiseptic swab prior to inserting a filter, blunt tip or regular needle into the stopper of a medication vial or ampule to withdraw medication.

Observation on 12/03/24 at 8:30 AM, showed Staff Y, RN, failed to clean her work surface and/or use a barrier prior to medication preparation and administration for Patient #4.

Observation on 12/03/24 at 9:05 AM, showed that Staff R, RN, failed to clean her work surface or place a barrier prior to medication preparation and administration for Patient #22.

Observation on 12/03/24 at 9:15 AM, showed that Staff S, CN, failed to place a barrier under Patient #23's arm prior to placing an intravenous catheter (IVC, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream).

Observation with concurrent interview on 12/03/24 at 10:00 AM, showed Staff V, Wound Nurse, failed to place a clean barrier under Patient #25's leg during a wound dressing change. He failed to use a barrier, placing the wound dressing supplies on the countertop adjacent to the sink. He stated that he did not us a barrier under Patient #25's leg because the wound was not "oozing."

Observation on 12/03/24 at 8:45 AM, showed Staff Z, RN, did not clean surface or use barrier prior to preparing medications for administration for Patient #27.

Observation on 12/03/24 at 9:45 AM, showed Staff CC, RN, prepared oral meds for administration without cleaning the work surface or using a barrier for Patient #29.

Observation on 12/03/24 at 3:20 PM, showed Staff J, RN, failed to clean a work surface or use a barrier when preparing medications for Patient #31.

Observation on 12/03/24 at 10:10 AM, showed Staff DD, RN, did not clean the work surface or use a barrier when preparing medication for Patient #32.

Observation on 12/04/24 at 8:30 AM, showed Staff WW, RN, failed to clean a work surface prior to preparing medications for administration at the nursing desk. She then placed the medications on the uncleaned and cluttered patient tray table without using a barrier, then administered Patient #45's IV medications.

During an interview on 12/04/24 at 8:50 AM, Staff H, Nurse Manager, stated she expected nursing staff to clean surface prior to medication preparation and administration.

During an interview on 12/04/24 at 8:50 AM, Staff D, Assistant Chief Nursing Officer, (ACNO), stated that she expected nursing staff to clean surfaces prior to medication preparation and administration.

During an interview on 12/05/24 at 12:05 PM, Staff B, CNO, stated that she expected a clean barriers to be placed beneath medications before medication administration, under wound dressing supplies, and under the area of a patient's wound during dressing changes.

Observation on 12/03/24 at 8:30 AM, showed Staff Y, RN, grabbed her badge with soiled gloves while performing wound care on Patient #4, continue with patient care without changing gloves.

During an interview on 12/03/24 at 2:15 PM, Staff Y, RN, stated she should have removed her gloves and performed hand hygiene prior to touching her badge.

Observation on 12/04/24 at 10:05 AM, showed Staff XX, RN, while replacing a dressing, reached in her pocket with gloved hand to answer her phone, then put her phone back in her pocket and continued with patient care for Patient #5.

During an interview on 12/04/24 at 10:40 AM, Staff XX, RN, stated she should have removed her gloves and performed hand hygiene prior to answering her phone and then again prior to continuing patient care.

Observation with concurrent interview on 12/03/24 at 10:00 AM, showed Staff V, Wound Nurse, failed to change gloves after picking up trash on the floor and touching the trash can during a wound dressing change on Patient #25. He stated he should have changed his gloves after touching the trash on the floor and the trash can, before touching the clean dressing supplies and the patient.

Observation on 12/03/24 at 9:15 AM, showed Staff S, CN, failed to perform hand hygiene after touching the patient, removing gloves and donning gloves while preparing supplies during an IV insertion for Patient #23.

Observation with concurrent interview on 12/03/24 at 10:00 AM, showed Staff V, Wound Nurse, failed to perform hand hygiene prior to entering the patient's room and donning gloves, after touching a trash can and after removing gloves while performing a wound dressing change on Patient #25. Staff V stated he should have performed hand hygiene before entering a patient's room, before putting on gloves, after removing dirty gloves and putting on new gloves. He should have performed hand hygiene after touching the trash on the floor and the trash can before touching the clean wound supplies and applying them to the patient.

Observation on 12/03/24 at 1:30 PM, showed Staff V, Wound Nurse, performed a dressing change and pressure injury assessment on Patient #27's tailbone area. When the patient was turned, he was found to have soiled himself. Staff V removed the old dressing and cleaned the patient of incontinence. He removed his gloves and donned new gloves without performing hand hygiene.

Observation on 12/04/24 at 8:30 AM, showed Staff D, RN, failed to perform hand hygiene after picking up trash off the floor for Patient #45.

Observation on 12/04/24 at 11:10 AM, showed Staff V, Wound Nurse, failed to perform hand hygiene after removing gloves, touching a dirty wound dressing and donning clean gloves while performing a wound dressing change for Patient #48.

During an interview on 12/05/24 at 12:20 PM, Staff B, CNO, stated she would expect nursing staff to complete hand hygiene before donning and doffing gloves, before entering and after exiting a patient's room and moving from a contaminated area to a clean area of the patient's body.

Observation on 12/04/24 at 8:45 AM, showed Staff Z, RN, failed to clean the rubber stopper of an IV medication prior to the insertion of the needle for medication withdrawal for Patient #27.

Observation on 12/04/24 at 8:30 AM, showed Staff WW, RN, failed to clean the rubber stopper of an IV medication prior to the insertion of the needle for medication withdrawal, then administered the IV medication to Patient #45.

During an interview on 12/05/24 at 12:20 PM, Staff B, CNO, stated she would expect nursing to clean the rubber topper of a medication vial with alcohol after "flipping off" the cap and withdrawing medication with a needle.

During an interview on 12/03/24 at 3:15 PM, Staff E, VPQ, stated she expected staff to clean the top of the vial of medication prior to withdrawal.


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