HospitalInspections.org

Based on observation, interview, and document review, nursing staff did not measure pressure injuries as per facility protocol, in 1 (one) of 3 (three) wound measurement observations.

Findings:

During observation of Staff C (Registered Nurse/RN) on 11/17/2021 at 1:30 PM, Staff C was observed using one cotton tipped applicator to measure three different pressure injury sites on Patient #2. Staff C used a cotton tipped applicator to measure for depth and tunneling in a Stage 4 Sacral ulcer where slight drainage was noted. Staff C then used the same contaminated cotton-tipped applicator to measure depth in a Right Posterior Ischium ulcer. Staff C then re-used the same applicator to measure the depth of a Left Ischium Wound.

As per interview with Staff D (Registered Nurse/RN) at the time of observation, Staff D stated that the Left Ischium Wound was new and was not present on admission.

On follow-up interview with Staff C on 11/18/2021 at 1:15PM, Staff C confirmed these findings and stated, "I was in over my head and shouldn't have done that."

During interview of Staff B (Director of Nursing for Quality Improvment) on 11/18/2021 at 2:15 PM, Staff B confirmed that the use of one cotton-tipped swab to measure more than one wound is not the standard and is not part of the nursing education.

The facility's Nursing Education document titled, "Wound Measurement Staff Education," last updated 2021 stated, "Use a clean cotton tipped applicator to measure depth (do not reuse) to prevent cross contamination."