HospitalInspections.org

Based on observation, interview, record review and policy review, the facility failed to obtain physician orders for wound care interventions, and communicate and implement wound care interventions to reduce the risk of pressure injuries (also known as pressure wounds or pressure ulcers, injury to the skin and/or underlying tissue, usually over a bony area) for patients who were assessed as high risk for skin breakdown for one current patient (#14) of two current patients with wounds reviewed. These failure had the potential to lead to hospital acquired pressure injuries (also known as pressure wounds or pressure ulcers, injury to the skin and/or underlying tissue, usually over a bony area) and further deterioration of existing pressure injuries. The facility census was 34.

Findings included:

1. Review of the facility's policy titled, "Skin Integrity (refers to skin health, to be free of wounds or irritation) Assessment including Pressure Injuries and Wounds," dated 10/12/18 directed staff to:
- Ensure appropriate interventions are completed based on skin and wound assessments.
- Ensure patients who are immobilized or deemed at-risk, have interventions that include and the application of pressure reduction boots (a heel protector that is designed to relieve pressure to the heels) and/or devices.
- Implement standing orders (physician approved, pre-printed orders for use with patients who have specific diagnoses) for pressure injury treatment on patients identified with Stage 1 (intact skin with a localized area of redness that does not go away when pressure is applied) or Stage 2 pressure injuries (a shallow opening in the skin with red or pink tissue, or may present as a fluid filled blister).

Review of the facility's policy titled, "Interdisciplinary Plan of Care," dated 01/10/19, directed staff to complete an initial assessment that included screening for potential referrals to other disciplines including skin integrity.

Review of Patient #14's medical record dated 05/10/19 through 05/15/19, showed:
- She was a 65 year old female who developed atrial fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow) in the ED.
- She had a history of hypotension (low blood pressure), peripheral vascular disease (blood circulation disorder that causes blood vessels outside the heart and brain to narrow, block or spasm that typically causes pain and tiredness in the legs), peripheral arterial disease (circulatory problem in which narrowed arteries reduce blood flow to your limbs) and uncontrolled diabetes mellitus (a disease when the body cannot rid itself of excess glucose/sugar in the blood and requires insulin [hormone] to control; uncontrolled diabetes may cause a disease of the blood vessels which can damage the kidneys, eyes, heart, and nerves and delay wound healing).
- She had a recent diagnosis of a deep vein thrombosis (DVT, formation of one or more blood clots in one of the body's large veins most commonly on the lower legs), osteomyelitis (inflammation of the bone caused by infection) xerosis (abnormal dryness of tissue that may have scales or small cracks) and hyperkeratoses (abnormal thickening of the outer layer of skin) with a recent amputation (surgical removal) of the right second toe.
- She had necrosis (dead tissue) to the right third toe.
- Both heels were dusky (dark in color, can indicate poor blood flow) in color with areas of blanchable redness (redness that disappears with finger pressure), that were assessed as being cool to touch, with poor capillary refill (indicates poor blood flow to skin, amount of time it takes for color to return to the skin, after pressure is applied).
- She was assessed as being at risk for skin breakdown and was to have had her heels offloaded (to reduce or eliminate pressure, to prevent pressure injuries) off the bed with a pressure-redistributing mattress.
-No physician orders, care plans, or progress notes were in place for directives to offload or implement pressure reducing interventions.

Observation on 05/14/19 at 9:45 AM, of Patient #14's treatment, along with concurrent interview, showed:
- The foot of the bed was adjusted to be in the downward position placing her lower extremities (legs) in the dependent position (to hang down).
- Her left heel was laying directly on the mattress and was not offloaded while she was in bed.
- Her pressure reduction boot laid on her sink and was not in place to offload her left heel.
- Staff U, RN, was unaware Patient #14 needed to have the pressure reducing boot on her left foot.

Dependent position, failure to offload the heal and failure to ensure the pressure reduction boot was in place, all increased the risk of pressure injury to the patient who was already at risk for skin breakdown.

During an interview on 05/15/19 at 9:28 AM, Staff BB, RN stated that:
- When wound documentation was completed, a consult to the wound nurse would automatically generate in the computer.
- She received face to face communication regarding wound care from the wound care nurse.
- The wound care nurse put standing orders in the computer for wound care.

During an interview on 05/14/19 at 2:12 PM, Staff F, RN, Wound Care Nurse stated that:
- She assessed patients with wounds at least once per week.
- The only way the staff nurses knew her recommendations for wound care was through the verbal communication at the bedside, after she assessed the wound.
- She documented her wound care note in the computer, used the standing wound care orders, talked to the nurse at the bedside, and called the physician if needed.
- She was unsure if an order was required for pressure reduction boots.
- Nurses should be able to use nursing judgement for interventions to reduce pressure injury risks.
- The goal for hospital acquired pressure wounds was zero, but the facility had an average of five per month.

Review of the facility's wound care tracking log showed that the facility had acquired pressure injuries each month in 2019, with five hospital acquired pressure injuries documented during several of the months.

During an interview on 05/15/19 at 8:18 AM, Staff W, Medical Doctor (MD), Chief Medical Officer stated that:
- Standing orders were used based on nursing staff judgement.
- The wound care nurse communicated to the nursing staff about the patients' wounds.
- The wound care nurse could initiate standing orders.
- The goal for hospital acquired pressure ulcers was zero and he knew there was a problem with pressure ulcers.
- That many of their metrics could be tied to current hospital culture and that their culture needed improved upon.

During an interview on 5/14/19 at 11: 00 AM, Staff A, Quality Supervisor, stated that hey were aware that acquired pressure ulcers had been an issue at their facility, with five facility acquired pressure ulcers documented in several months in the current year, and their system of communication and documentation of patient care interventions for those at risk for skin breakdown had not been effective.







39840

Based on observation, interview, record review and policy review, the facility failed to ensure nursing staff performed hand hygiene according to policy, for two current patients (#3 and #14) of six patients observed during care. This failed practice had the potential to lead to the spread of infection and disease, and could affect all patients, staff and visitors. The facility census was 34.

Findings included:

1. Review of the facility's policy titled, "Personal Protective Equipment and Engineering Controls," dated 10/03/18 directed staff to:
- Perform hand hygiene before putting on gloves.
- Change gloves after you have finished cleaning a soiled area, before performing the next task, or when integrity of the gloves are in doubt.
- Perform hand hygiene after removing gloves.

Review of the facility's policy titled, "Hand Hygiene," dated 10/10/16 directed staff to:
- Perform hand hygiene before and after each patient contact.
- Perform hand hygiene before, between, and after glove changes.
- Perform hand hygiene after removing gloves.

Review of Patient #14's medical record dated 05/10/19 through 05/15/19, showed she was treated for clostridium difficile (C. diff, highly contagious bacteria that causes diarrhea and can be life threatening), with a recent amputation (surgical removal) of the right second toe and necrosis (dead tissue) to the right third toe.

Observation on 05/14/19 at 9:45 AM, showed Staff U, Registered Nurse (RN), failed to perform hand hygiene during Patient #14's dressing removal (soiled area) and dressing reapplication (should remain as clean as possible).

Observation on 05/13/19 at 3:42 PM, showed Staff J, RN, failed to perform hand hygiene after she removed her gloves during Patient #3's care.

Observation on 05/14/19 at 8:50 AM, showed Staff O, RN, failed to perform hand hygiene after she removed her gloves during Patient #3's care.

Observation on 05/14/19 at 9:02 AM, showed Staff P, RN, failed to perform hand hygiene after she removed her gloves during Patient #3's care.

During an interview on 05/14/19 at 1:57 PM, Staff Q, RN Infection Preventionist, stated that she expected staff to perform hand hygiene before they entered a patient's room, before they applied gloves and after they removed gloves.

During an interview on 05/14/19 at 3:42 PM, Staff T, RN, Coordinator of Nurse Development, stated that she provided education on hand hygiene to nursing staff upon hire.

During an interview on 05/15/19 at 9:06 AM, Staff Z, RN, Educator, stated that she provided education on hand hygiene to staff.

During an interview on 05/15/19 at 8:18 AM, Staff W, Doctor of Medicine (MD), Chief Medical Officer, stated that hand hygiene should be performed every single time before gloves were applied and after gloves were removed.

During an interview on 05/15/19 at 9:17 AM, Staff AA, RN, Emergency Department Charge Nurse, stated that hand hygiene should be performed before staff entered a patients' room, when staff exited a patient's room, before gloves were applied, and after gloves were removed.