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Based on observation, interview, and record review, the facility failed to ensure licensed staff performed infection prevention procedures during wound care for one of 20 sampled patients (Patient 6). Specifically, licensed staff failed to change soiled gloves and perform hand hygiene during care of an infected wound. The deficient practice put Patient 6 at risk for development of additional wound infections.

Findings Include:

Review of an admission "History & Physical," dated 11/16/18, showed the facility admitted Patient 6 for ongoing physical therapy due to general weakness. "Medical History," included "Small cell lung cancer, coronary artery disease and pulmonary embolism (blood clot in the lung)."

On 12/11/18 at 10:00 AM, Patient 6 was observed seated in a reclined chair at bedside. Patient 6 stated, "I can sit up for a while but not too long, my bottom starts to hurt, and I have to lay down." Patient 6 was on contact precautions (contact precautions are used for diseases transmitted by contact with the patient or the patient's environment).

On 12/11/18 at 10:15 AM, Staff C, Registered Nurse, (RN) stated, "Patient 6 has a wound on the buttock. Patient 6 had an abscess and it was surgically lanced last week. The wound is infected, and Patient 6 is on contact precautions for MRSA (MRSA-Methicillin-Resistant Staphylococcus Aureus-a bacterium that is resistant to antibiotics and is transmitted by contact with the patient's body or the patient's environment)." Staff C stated, "Patient 6 also has a pressure sore on the coccyx. I'm going to change Patient 6's dressings this morning."

Review of a "Nurse Note," dated 11/28/18 at 6:30 AM, showed Patient 6 was observed to have an open sore on the tail bone. The "Nurse Note," showed, "Open sore on tail bone discovered and Mepilex applied." There was no further documentation regarding the description of the "open sore."

Review of the "Patient Care Assessment," dated 11/29/18, showed, "Pressure injury stage 2. Length 2.5 centimeters (cm), Width 0.5 cm. Yellow slough. Scant sanguineous [bloody] drainage. Wound care-Use Prisma and foam on skin breakdown on coccyx every other day."

Review of a "Nurse Note," dated 12/05/18 at 5:04 AM, showed a boil was observed on the left upper buttock. The "Nurse Note," showed, "Small boil noted to left upper buttocks. Small black scabbed area to mid-left buttocks. Area is hard to touch. Wound care-Saline soaked packing with Mepilex border daily change, wound cleanser for cleaning wound."

Review of a "View Order Detail," dated 12/07/18, showed, "Please arrange for patient to be transported by private vehicle to be seen through emergency room for evaluation of buttock abscess."

An "Operative Report," dated 12/07/18 showed, "Preoperative diagnosis: Perianal abscess ... incision and drainage of perianal abscess ... the patient was taken to the operating room and placed on the operating table in the lateral position. The area was prepped and draped. Local was injected. A 2 cm incision was made. All the purulent pus was drained. We packed the wound. The patient tolerated the procedure well."

Review of a "Wound Care Culture," dated 12/07/18, showed, "Final result ... Source: Wound ... site buttock ... Bacteria-moderate gram-positive cocci ... Moderate amount of Methicillin Staphylococcus aureus (MRSA)."

On 12/11/18 at 11:00 AM, Staff C was observed providing wound care to Patient 6. Staff C donned a personal protective gown and gloves and entered the room. Staff D, Patient Care Technician, (PCT) assisted Patient 6 onto his/her right side in bed and exposed his/her buttocks by removing the brief and top covers. Patient 6 had a bleeding surgical wound (where the abscess (boil) had been incised and drained) on his/her left buttock that did not have a dressing applied. Staff D stated, "His/her dressing came off and the packing came out." Staff C asked Staff D "How much packing was in the wound?" Staff D stated, "I don't know, it was very bloody." The infected surgical wound was bleeding and there was blood on the bed linens. Staff C retrieved wound care products from a plastic bath basin placed on the sink near the bed. Staff C placed the clean wound care products on the bed next to Patient 6's back. Staff C picked up a spray bottle of wound cleanser that she had placed on the bed and sprayed the surgical wound. After spraying the wound, Staff C used a 4X4 square gauze to wipe the bloody drainage from the wound. Staff C removed a pair of bandage scissors from a plastic bag and removed the lid from a bottle of packing strip gauze. Staff C used the tip of the scissors to pull the packing gauze out of the bottle and placed the tip of the scissors next to the wound touching the upper edge of the wound with the scissors. Staff C did not sanitize the scissors when she took them out of the plastic bag. Staff C used a cotton tip swab to pack the wound and placed an adhesive dressing over the wound. Staff C placed the soiled scissors on the sink near the bed and reached into the bath basin with the soiled gloves to remove additional wound care dressings. Staff C did not remove the soiled gloves or wash her hands. Staff C used the spray bottle of wound cleanser that was laying on the bed to spray the pressure injury on the coccyx. The pressure injury on the coccyx (tailbone) was located approximately 4-5 inches above the surgical wound on the left buttock. After spraying wound cleanser on the pressure injury, Staff C wiped the pressure injury with a 4X4 gauze and covered the pressure injury with an adhesive dressing. Staff C did not remove the soiled gloves before providing wound care to the pressure injury and contaminated the pressure injury. Staff C placed the bath basin on a shelf across from the bed and opened the cubicle curtains with the soiled gloves. Staff C patted Patient 6 on the back with the soiled gloves and asked if he/she was alright. Staff C did not change gloves or perform hand hygiene during the procedure.

On 12/11/18 at 11:35 AM, Staff A, Director of Nursing, (DON) was informed of the wound care observation with Patient 6. Staff A stated, "She should have changed her gloves. We will move the patient and do a terminal clean of the room. She will receive education on infection control and wound care. I'll have our Infection Prevention Officer (IPO) educate the nurse."

On 12/12/18 at 2:30 PM, Staff F, IPO, confirmed that she had provided education to Staff C regarding infection prevention procedures during wound care. Staff F stated, "Yes, I sat with her yesterday and reviewed hand hygiene, contact precautions and basic wound care dressing changes. I wrote an action plan and I will make sure we watch the pressure ulcer."

Review of the CAH's policy, "Isolation Precautions," dated 11/29/18, showed, "The purpose of this document is to provide instructions for preventing transmission of microorganisms through defined isolation precautions ... Isolation precautions are designed to stop the spread of infected microorganisms by eliminating the means of transmission. Gloves: Wear gloves when touching blood, body fluids, secretions, excretions, and contaminated items, mucous membranes or non-intact skin ... change gloves between tasks and/or procedures on the same patient after contact with material that may contain microorganisms ... remove gloves promptly after use and before touching non-contaminated items. Change gloves after having contact with infective materials ... feces and/or wound drainage." The hospital's nursing staff was not following their policy.

Review of the CAH's policy, "Wound Cleaning" dated 05/10/18, showed, "Wounds are cleansed as part of the dressing change with the prescribed solution...Procedure: perform hand hygiene, prepare supplies using sterile technique...when finished cleaning wound, removed gloves, wash hands and re-glove with a clean pair." The hospital's nursing staff was not following their policy.

Based on record review, observation, interview, document review, and policy review, the facility failed to ensure that licensed staff provided accurate and consistent assessment of a pressure injury for one of 20 sampled patients (Patient 6). This deficient practice had the potential for severe harm or death related to the national standard of care that was not provided leading to a contracted virulent bacterium.

Findings Include:

Review of an admission "History & Physical," dated 11/16/18, revealed the facility admitted Patient 6 for ongoing physical therapy due to general weakness. "Medical History," included "Metastatic small cell lung cancer, coronary artery disease and pulmonary embolism (blood clot in the lung)."

Review of a "Nurse Note," dated 11/28/18 at 6:30 AM, revealed Patient 6 was observed to have an open sore on the tail bone. The "Nurse Note," showed, "Open sore on tail bone discovered and Mepilex applied." There was no further documentation regarding the description of the "open sore."

Review of a "Patient Care Assessment," dated 11/29/18 at 06:00 AM, showed, "Pressure injury stage 2. Length 2.5 centimeters (cm), Width 0.5 cm. Yellow slough. Scant sanguineous [bloody] drainage. Wound care-Use Prisma and foam on skin breakdown on coccyx every other day."

On 12/11/18 at 11:00 AM, Patient 6 was observed on his/her right side in bed. Staff D, Patient Care Technician (PCT) exposed Patient 6' s buttocks by removing the brief and top covers. Patient 6 had a pressure injury on the coccyx [tailbone] that was approximately 2-3 centimeters (cm) in diameter. The pressure injury had yellow slough (dead tissue that adheres to the tissue bed).

On 12/11/18 at 2:00 PM, Staff A, Director of Nursing, (DON) and Staff E, Outpatient Nurse Supervisor, (ONS) were interviewed concurrently. Staff A reviewed the "Patient Care Assessment" dated 11/29/18 and stated, "I'm wound certified and I know that's not accurate. A stage 2 pressure injury does not have slough. I haven't seen the wound, but I'll do an assessment on it." Staff E stated, "I was consulted regarding the wound. The nurse told me about it, but I didn't measure it at the time. I recommended Prisma which is a collagen. I didn't document any stage or size. I saw it last on 12/08/18 and there were no changes. I didn't measure or stage it. It was about 3 cm."

On 12/11/18 at 3:45 PM, Staff A provided a copy of the completed pressure injury assessment. The "Item Detail" showed, "Tuesday December 11 at 3:31 PM ... left upper buttock stage 3...no drainage...wound bed shiny...Length 2.5 cm...Width 2 cm...Depth 0.1 cm." Staff A stated, "Here's the measurement, unfortunately, there were no measurements at the time of the initial observation and no measurements since that time. The initial assessment was inaccurate, the pressure injury should have been measured weekly. I'll educate the nurses on pressure injury assessments."

On 12/11/18 at 4:00 PM, Staff B, Administrator provided copies of the clinical record and stated, "I reviewed the wound documentation and there were no weekly measurements of the wound."

Review of "Item Detail-Pressure Injury," that Staff B, Administrator, provided dated 12/02/18 through 12/11/18, revealed no pressure injury measurements or staging had been completed. The "Item Detail-Pressure Injury" documents included, "Pressure injury dry & intact," on dates 12/02/18 through 12/11/18.

Review of the CAH's policy, "Wound Measurements," dated 06/11/18, showed, "Nursing Associates will be knowledgeable in the tools, assessments and interventions used to prevent pressure ulcers. The assessment of care and treatment needs of the patient will be ongoing throughout the patient's hospital stay...Purpose: To provide consistent wound measuring guidelines to determine improvement of the wound...Responsibility-Director of Nursing...Procedure-A registered nurse shall measure a patient's wound in centimeters at least one time each week. Measurements taken will be: Length, Width, Depth. The National Pressure Ulcer Advisory Panel (NPUAP) defines a pressure ulcer as, a localized injury to the skin and/or underlying tissue usually over a boney prominence...Stage 2: Partial thickness skin loss involves the dermis...The ulcer is superficial open ulcer with a red-pink wound bed. No slough or bruising...Stage 3: Full-thickness skin loss...Subcutaneous fat may be visualized...slough may be present, but the depth of tissue loss can still be seen." The hospital's staff was not following the policy.

Professional Reference: National Pressure Ulcer Advisory Panel (NPUAP), Pressure Ulcer Stages Revised by NPUAP, February 2007, http://www.npuap.org/pr2.htm

"The National Pressure Ulcer Advisory Panel (NPUAP) serves as the authoritative voice for improved patient outcomes in pressure injury prevention and treatment through public policy, education and research. The staging system includes the following definitions: Pressure injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominenc...the injury can present as an open ulcer...Stage 2 Pressure injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist and may also present as an intact or ruptured serum-filled blister...slough and eschar are not present. Stage 3 Pressure injury: Full thickness skin loss, in which adipose fat is visible in the ulcer...slough and/or eschar may be visible."