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Based on review of the Alabama Board of Nursing Chapter 610-X-6.13 Standards for Wound Care, Potter-Perry Fundamentals of Nursing, hospital policies and procedure, hospital "Charting Cheat Sheet Med Surg (medical surgical)", medical records (MR) and interviews with administrative and direct care staff, it was determined the hospital failed to ensure nursing staff:

1) Measured wounds to establish baseline wound assessments and documented the appearance of wound sites including the condition of the wound bed, the appearance of the skin surrounding wounds and the presence/absence of exudate.

2) Identified and documented integumentary (skin) status changes at onset which included a stage 2 (partial thickness skin loss involving epidermis/and/or dermis) pressure injury and (US) unstageable (wound base/depth is obscured) bil (bilateral) buttock pressure injuries.

3) Performed Mepilex preventative dressing changes according to wound care team recommendations and wound care orders.

4) Provided wound care as ordered to all wound sites and documented all care provided to wounds.

This affected PI (Patient Identifier) # 4, PI # 3, PI # 1, 3 of 6 wound records reviewed, and had the potential to negatively affect all patients with wounds.

Findings include:


Alabama Board of Nursing Chapter 610-X-6 Standards of Nursing Practice

...610-X-6-.03 Conduct and Accountability. The registered nurse or licensed practical nurse shall:

...(15)Accept individual responsibility and accountability for accurate, complete, and legible documentation related to:
(a) Patient care records...

...610-X-6.13 Standards for Wound Care

(1) It is within the scope of a registered nurse (RN)...to perform wound assessments including...making determination as to whether wounds are present on admission...
(2) The minimum training for the RN...associated with wound assessment and care include:
(e) Risk identification.
(f) Measurement of wound
(h) Condition of the wound bed including:
(i) Tissues
(ii) Exudate
(iii) Edges
(iv) Infection
(i) Skin surrounding the wound...

Potter-Perry Fundamentals of Nursing
6th Edition
Chapter 47 Skin Integrity and Wound Care
pages 1487- 1501

Classification of Pressure Ulcers
Pressure ulcers must be assessed at regular intervals using systematic parameters to evaluate would healing...and evaluate progress. Assessment should include depth of tissue involvement, type and approximate percentage of tissue in wound bed, wound dimensions, exudate description, and condition of surrounding skin...Wound dimensions should include consistent measurements of depth (D), length (L) and width (W). Exudate describes the amount, color, consistency, and odor of wound drainage...

Nursing Process Assessment
Baseline and continual assessment data provide critical information about the client's skin integrity and the increased risk for pressure ulcer development.

Skin. The nurses continually assesses the skin for signs of ulcer development...Assessment for tissue pressure ulcer indicators includes visual and tactile inspection...baseline assessments is performed to determine..skin characteristics and any actual or potential areas of breakdown...

Hospital Policy: Nursing Patient Care
Title: Skin Integrity: Preventing Loss of Skin Integrity
Review Date: 2/2020

I. PURPOSE...to identify patients at risk and/or with loss of skin integrity and provide guidelines to maintain the skin integrity of the patient.
II...applies to all hospitalized patients...at risk for skin breakdown or who have skin breakdown.

III.
Braden Risk Assessment Scale- Risk assessment scale based on risk factors and subscales which predict patients at risk for developments of a pressure injury.
Pressure Injury (PI)-Localized damage to the skin and underlying soft tissue usually over a bony prominence...The injury can present as intact skin or an open ulcer...

IV. Guidelines: For guidelines...refer to Mosby's Skills...
Document daily skin assessment, any skin changes, and unexpected outcomes in the medical record and consult Wound Care for assessment, treatment and recommendations.

Skills Pressure Injury: Risk Assessment and Prevention...Overview
The most common sites for pressure injuries include occiput, sacrum, coccyx...heels...
Inspection of the patient's skin and bony prominence should occur at least daily...

ASSESSMENT...
6. Perform risk assessment...
8. Assess the condition of the patient's skin over pressure points...
a. Inspect...Palpate the discolored area for blanching...skin temperature differences...

PROCEDURE
12. Create a schedule for position changes.
13. Consider applying a prophylactic dressing (e.g., polyurethane foam) to bony prominence's (e.g., heels, sacrum)
20. Document the procedure in the patient's record.

MONITORING And CARE
1. Observe the patient's skin for risk areas for change..
5. Report to the practitioner the need for additional consultations...wound care specialist...

EXPECTED OUTCOMES
No change from baseline skin assessment occurs
Skin is intact with no evidence of erythema and no signs of breakdown.

UNEXPECTED OUTCOMES
...Skin breakdown and/or pressure injury develops

DOCUMENTATION
Patients risk score and skin assessment
Any skin changes
...Patient's response to the interventions
...Unexpected outcomes and related nursing interventions...

Hospital Policy: Patient Care Policy and Procedure Manual
Title: Assessment/Reassessment of Patients
Revision Dates 12/19

I. PURPOSE:
A. To establish guidelines for the assessment and reassessment function across the continuum of care.
B. To define the appropriate care, treatment and services to meet the patient's initial needs...or changing needs...
1. Collect data about each patient's care...
2. Analyze the data to produce information about patient's needs.
3. Making care, treatment...and service decisions and/or recommendations based on the information gathered...and his or her response to care, treatment, and services...

C. Reassessment-Patients are reassessed as needs...or changes in their condition...

2. Licensed Nursing Staff
a. A physical assessment (head to toe) is initiated upon admission and with a change in caregivers...reassessment of pertinent physical findings...appropriate to the physical status/condition...Documentation of routine patient care delivery is done by exception.
c. Documentation of physical assessment upon change in caregivers is comprehensive as appropriate for the patients. All other charting is done by 'exception'-only pertinent physical system assessment/treatments/other responses to care are documented in the medical record for changes in patients physical status, changes in condition/diagnosis and treatments...

Charting Cheat Sheet Med Surg "Guidelines"

Admissions...Transfers...Others

...Chart Oral Care, Foley Care...Wound Care, Dressing Change, Site Appearance...

In an interview on 11/9/2020 at 1:13 PM, EI (Employee Identifier) # 1, System Vice President Quality Manager reported the hospital policy allows nursing staff to "chart by exception". EI # 1 reported "wound nurses perform wound measurements."

1. PI # 4 was admitted to the hospital on 9/1/2020 with diagnoses including Car Versus Train, C (cervical) Spine Fractures C5-6 and Burst Fracture of T3 (thoracic). On 9/3/2020 a spinal discectomy and anterior fusion was performed. On 9/4/2020 the patient had a syncopal episode, developed bilateral pulmonary embolism with respiratory distress and tested positive for COVID-19 on 9/10/2020. The patient was transferred from Intensive Care on 9/15/2020 at 2:51 PM to the med surg unit and discharged on 9/24/2020.

Review of the 9/15/2020 9:00 AM Assessment of Integumentary Status Focused Assessment documented by nursing staff revealed a bruise to the left and right buttock and right flank and generalized nonpitting edema. At 1:00 PM, an unchanged Assessment of Integumentary Status was documented. At 6:00 PM, Assessment of the Integumentary Status Focused Assessment revealed skin integrity not intact, skin symptoms none and generalized edema, At 10:00 PM, the Assessment of the Integumentary Status Focused Assessment revealed skin not intact, skin symptoms bruising, Braden 15 (moderate risk for skin breakdown). The skin abnormality documented was bruise to the left and right buttock and right flank.

Review of the nursing documentation dated 9/18/2020 at 7:48 AM, Integumentary Focused Assessment revealed skin intact, warm, dry, elastic, skin symptoms none. At 11:39 AM and 3:23 PM, the Integumentary System Assessment documentation was "unchanged from the previous assessment".

Record review revealed an ET (Enterostomal) Therapy Note dated 9/18/2020 at 5:32 PM which revealed a wound consult evaluation. Findings documented by the EI # 3, RN (Registered Nurse), Inpatient WOC (Wound Ostomy Continence) Program Coordinator, were irregular shaped bilateral buttocks, unstageable wounds and natal cleft with adherent slough. EI # 3 documented the presence of a healing stage 2 pressure injury to the R (right) buttock with thin brown drainage noted to dressing removed. No foul odor, drainage, erythema, or induration noted. The bilateral heels were intact.

MR review revealed 9/18/2020 WOC recommendations, clean buttocks daily with NS, apply Santyl, cover with Xeroform gauze, apply Mepilex with careful placement to separate buttocks; apply Mepilex heel dressing, change Mepilex dressing every 3 days and/or if heavily soiled. WOC nurse reassessment on 9/21/2020.

There was no MR documentation staff identified upon onset integumentary/skin status changes of the stage 2 right buttock pressure injury.

The 9/18/2020 ET Therapy Note had no baseline wound measurements documented, length (L), width (W) and depth (D) for the pressure injury areas and no wound bed descriptions were documented. There was no documentation of the appearance of the skin surrounding the bil (bilateral) buttocks or the absence/ presence of wound drainage/exudate. There was no measurements for the size/area of involvement to the healing stage 2 R buttock pressure injury.

The nurse documentation of the integumentary/skin assessment on 9/18/2020 from 7:48 AM to 3:23 PM failed to include the development of and appearance of the bilateral buttock wounds, natal cleft and right buttock wound which required a wound care consult.

Review of Wound care orders dated 9/18/2020 at 5:18 PM revealed clean bil buttocks and Natal Cleft daily with NS (normal saline) apply Santyl ointment, cover with Xeroform gauze and apply Mepilex dressing with careful placement to separate buttocks.

In addition, wound care orders dated 9/18/2020 at 5:21 PM were to assess heels daily, apply Silicone (Mepilex) heel dressing (no frequency of Mepilex application though ET recommendation were every 3rd day), date dressing each day of assessment.

Review of the ET Therapy Note wound re-assessment completed by EI # 4, WOCN (wound ostomy continence nurse) on 9/21/2020 at 4:45 PM revealed a left buttock (US) unstageable pressure injury measured ( L) 3 cm x (W) 2 cm with softening yellow slough and small amount yellow drainage. R buttock US pressure injury measured (L) 1.5 cm x (W) 1 cm, yellow slough in center, pink wound edges. Natal cleft US pressure injury measured (L) 4 cm x (W) 2 cm, adherent yellow slough. There was no documentation of the surrounding skin appearance to any of the pressure injuries.

There was no documentation the heels were assessed and no documentation the Mepilex heel dressings were changed every 3 days on 9/21/2020 per the 9/18/2020 ET recommendations and the 9/18/2020 5:21 PM wound order.

In an interview on 11/09/2020 at 2:00 PM, EI # 4 reported to the surveyor the WOCN wound consultant usually measures the wound and documents the wound appearance. EI # 4 reviewed the 09/21/2020 ET re-assessment documentation and stated "I didn't document anything about skin surrounding the buttocks". There was no documentation of the bil heel assessment and no documentation the bil heel Mepilex dressing was changed every 3 days. EI # 4 stated "I don't remember anything about the heels".

Review of the 9/22/2020 9:45 AM nurse documentation completed by EI # 7, RN # 2, 3 N (North) Unit included Assessment of Integumentary Status, Focused Assessment. EI # 7 documented intact skin integrity, Braden Score 14 (Moderate Risk), and skin symptoms were none. There was no documentation of the left and right buttocks US pressure injury and no bil heel assessment. On 9/22/2020 at 11:47 AM and 4:00 PM, an Assessment of Integumentary Status documentation revealed "unchanged from previous assessment".

Further review revealed on 9/22/2020 at 10:00 PM, Assessment of Integumentary Status, Focused Assessment documentation included skin integrity dry, intact, Braden Score 14 and skin symptoms were none. There was no documentation of the presence/appearance of the bil buttocks pressure injuries.

In an interview on 11/9/2020 at 3:30 PM, EI # 7, RN # 2, 3 N reported she/he recalled the patient and stated "I did wound care". EI # 7 reviewed the 9/22/2020 nurse documentation and EI # 7 "stated I don't remember looking at the feet."

In an interview on 11/10/2020 at 1:13 PM, EI # 5, RN, Unit Manager, 2 N confirmed Santyl ointment was applied, however, there was no documentation the buttocks were cleansed with NS, Xeroform gauze and a Mepilex dressing was applied. There was no documentation staff performed the wound care according to physician orders.

MR review revealed no documentation of the daily heel assessment after 9/20/2020.

Written questions submitted 11/11/2020 at 8:20 AM to EI # 2, Director Risk Management included why WOC staff were notified of the 9/18/2020 wound consult as no changes in the skin integumentary status were documented and why no baseline wound measurements and complete wound appearances were not documented?

In an interview on 11/12/2020 at 9:40 AM, EI # 3, RN, Inpatient WOC Program Coordinator reported "we ask the nurse to give us a description of what they see when they make a wound consult." EI # 3 reported no recall of who (RN/physician) requested the wound consult. EI # 3 stated the WOCN should document baseline and ongoing wound measurements and wound appearances. EI # 3 confirmed she completed the 9/18/2020 consult but failed to document baseline wound measurements, condition of the wound bed, edges, and the appearance of the skin surrounding the wound. EI # 3 reported "the patient was ready to eat."

On 11/12/2020 at 10:45 AM, EI # 2, Director, Risk Management provided the surveyor physician notification dated 9/18/2020 5:32 PM regarding the ET consult wound/skin due to a sacral wound. EI # 2 confirmed the sacral wound was an unexpected outcome, a change in PI # 4's skin integument. The MR documentation failed to include skin assessment findings that required a wound consult.

2. PI # 3 was admitted to the hospital on 7/25/2020 with diagnoses including Acute Respiratory Failure, Pneumonia, Persons under Investigation COVID- 19, Recent Urinary Tract Infection. PI # 3 was discharged on 9/26/2020.

MR review revealed Wound Care Orders dated 9/21/2020 at 7:16 PM right of face/cheek, (clean with) NS, (apply) Medihoney Gel, bandaid. On 9/22/2020 at 9:00 AM, right cheek, NS, Medihoney Gel and Mepilex (if able) ; Sacrum/coccyx -clean daily with NS, apply Santyl ointment and fill with 1/2 of one saline moistened 4 x 4 (gauze) or Xeroform, cover with Mepilex, change daily.

Review of the 9/22/2020 nurse documentation revealed at 8:00 AM Assessment of Integumentary Status, skin symptoms none, skin abnormality was pressure ulcer coccyx midline wound, dressing assessment scant drainage. At 11:22 AM, Assessment of the Integumentary Status was unchanged from previous assessment. At 1: 48 PM and 3:35 PM, nursing documentation revealed a clean dry intact coccyx midline dressing. At 8:32 PM, Assessment of Integumentary Status, Focused Assessment revealed skin not intact, Braden 15, coccyx midline dressing assessment dry, intact.

There was no documentation wound care was performed to the right of face/cheek wound on 9/22/2020.

Review of the 9/23/2020 11:00 AM ET Therapy Note documentation revealed a healing trach (tracheostomy) wound, (L) 0.5 cm(centimeter) x (W) 0.5 cm with recommendations to cleanse trach site twice daily with moistened NS gauze, cover with Vaseline gauze, cover with Mepliex or dry dressing. Wound orders dated 9/23/2020 at 1:13 PM for the trach wound were NS gauze, Vaseline gauze, Mepliex or Optifoam dress.

Review of the nurse documentation on 9/24/2020 at 8:00 AM and 3:08 PM, Assessment of the Integumentary Status, Focused Assessment revealed the presence of the coccyx midline pressure wound. At 11:19 AM the integumentary assessment was unchanged from the previous assessment. At 8:19 PM, Assessment of the Integumentary Status, skin not intact, skin symptoms were bruising, ulcers/lesions. There was no documentation wound care to the sacrum/coccyx, right cheek and trach wounds were performed 9/24/2020.

On 11/10/2020 at 12:30 PM, Computer Navigator, EI # 5, RN Nurse Manager, 2 N and the surveyor reviewed the electronic health record. EI # 5 confirmed there was no documentation the wound care was completed 9/24/2020. There was documentation identified, the "Task was rescheduled".

In an interview on 11/10/2020 at 1:45 PM, EI # 11, RN, 5 N, viewed the electronic and printed documents. EI # 11 reported "if I did the care, its under notes, its a possibility I don't remember." EI # 11 recalled the cheek abrasion and reported he/she was certain wound care to the right face/cheek was completed one day. EI # 11 did not remember the trach site and could not recall the reason the wound task was rescheduled. There was no documentation wound care to the sacrum, trach and right cheek was performed 9/24/2020 and no reason documented why the wound task was rescheduled. EI # 5 and EI # 11 confirmed the above findings.



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3. PI # 1 was admitted to the facility on 09/13/2020 with Hypoxic Respiratory Failure and history of diagnoses including Unspecified Dementia without behavioral disturbance, Hypertension, Hypersensitivity Lung Disease (HLD), Afib (Atrial Fibrillation), and Breast CA (Cancer) with Mastectomy.

MR review includes Enterostomal Therapy Note dated 09/16/2020 for Wound Care Team Rounds with Physician and Registered Nurse (RN), Certified Wound and Ostomy Care Nurse (CWOCN) to assess skin status. Documentation revealed an unstageable deep tissue injury with multiple scattered fluid filled blisters over the sacrum, coccyx and towards the buttocks. The wound measured 14 cm by 10 cm with the fluid filled blisters mostly to the left side of the natal cleft. Periwound skin intact.

Review of the Physician Order dated 09/16/2020 revealed for the sacral area to be cleaned twice daily, every 12 hours (9 AM, 9 PM) with foam soap, apply venelex, cover with single layer petroleum gauze or xeroform gauze and Mepilex.

Review of the nurses notes dated 09/18/2020 revealed documentation of the dressing type and assessment of the dressing but failed to document the dressing was changed, venelex was applied, then covered with petroleum gauze or xeroform gauze and Mepilex.

Review of all nurses notes dated 09/19/2020 revealed no documentation that venelex, petroleum gauze or xeroform gauze was applied to the sacral wound as ordered.

Review of nurse note dated 09/26/2020 at 12:00 PM revealed sacral area cleaned and Mepilex changed, but failed to document venelex was applied to the wound then covered with petroleum gauze or xeroform gauze prior to changing Mepilex.

Review of nurse note dated 09/26/2020 at 9:00 PM revealed documentation of dressing type and assessment of the dressing over the sacral area but failed to document the wound was cleaned with foam soap, venelex applied, covered with petroleum gauze or xeroform gauze and Mepilex.

Review of Wound Care Notes dated 10/08/2020 revealed reassessment of unstageable pressure injury to buttocks/sacrum extending across midline to both left and right buttocks. Overall wound measurement 9 cm x 16 cm with adherent yellow/tan slough. When left and right buttocks are separated, deep natal cleft was shown to have 5 cm x 3 cm area of black to dark green thin eschar which was conservatively debrided. "Wound bed in this area is not visible but with depth of 1.5 cm it will likely be a stage 3-4 pressure injury." Slight odor noted.

Review of Physician Order dated 10/08/2020 at 5:53 PM and recommendations from wound nurse dated 10/08/2020 revealed daily wound care to sacrum/buttock/deep natal cleft: flush wound with normal saline (NS), apply Santyl to Vashe moistened roll gauze and gently pack depth of wound. Mepilex cover dressing. Continue to apply Santyl on xeroform daily to surface level buttocks wound, clean with NS or Vashe.

Review of nurses notes dated 10/09/2020 at 04:00 AM revealed sacral area cleaned with sterile saline and Santyl was a topical agent but failed to document sacral area had Santyl applied to Vashe moistened roll gauze and gently pack depth of wound and Mepilex cover dressing applied nor was it documented that Santyl was applied to xeroform to surface level buttocks wound as ordered.

Review of Physician Order dated 10/09/2020 at 9:00 AM revealed normal saline, Santyl on petrolatum gauze. Mepilex sacral dressing. Please do not use wound cleanser spray (this negates Santyl). Can use petrolatum gauze or xeroform gauze.

Review of nurses notes dated 10/09/2020 at 11:00 AM revealed Santyl applied to bed of wound, Vashe moistened kerlix packed inside stage 3-4 wound. Documentation failed to show wound was cleaned and normal saline utilized as ordered.

Review of Wound Care Note dated 10/22/2020 revealed reassessment of the sacral wound. Dressing with darkened bloody drainage. Wound measures 6 cm x 3 cm x 4 cm with 100% necrotic tissue with undermining and tunneling noted. Foul odor noted to the wound. Adherent brown and black eschar noted to the right buttock.

Review of Physician Order dated 10/27/2020 at 9:00 AM revealed sacrum/buttock/deep natal cleft: flush wound with NS, apply Santyl to Vashe moistened roll gauze and gently pack depth of wound.

Review of Physician Order dated 10/27/2020 at 10:00 AM revealed to gently pack sacral wound and adjacent necrotic skin with Dakin's 1/4 strength twice daily.

Review of nurses notes dated 10/28/2020 revealed no documentation that wound care was provided as ordered.

In interviews conducted on 11/10/2020 with EI # 8, RN Computer Navigator, EI # 9 RN and EI # 10 RN, it was confirmed there were gaps in wound care documentation and if wound care was performed, it was not documented clearly with the steps taken. It was unclear if wound care was actually performed as ordered.

Based on observations, review of the Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report, hospital policy and procedure, and interviews, it was determined the hospital failed to ensure staff followed the hospital hand hygiene policy during care of wounds.

This affected PI (Patient Identifier) # 6 and PI # 7 in 2 of 2 wound care observations and had the potential to negatively affect all patients admitted to the hospital.

Findings include:

Hospital Policy: Infection Control
Title: Hand Hygiene
Review Date: 3/2020

I. PURPOSE:

To decrease the risk of transmission of infection by use of appropriate hand hygiene.

III. BACKGROUND/RATIONALE:

Hand hygiene is generally considered the single most important procedure for preventing healthcare associated infections...

6. Hand hygiene-A general term that applies to either handwashing, antiseptic hand wash...

V. Policy:

To disrupt the transmission of microorganisms, health care workers are to practice hand hygiene at the key points in time such as the following:

c. After contact with contaminated surfaces (even if gloves are worn)
d. Before invasive procedures
e. After removing gloves (wearing gloves; is not enough to prevent transmission of pathogens in health care settings)

VI. PROCEDURE:
Hand washing

When hands are...
a. Wash well under running water for a minimum of 15-20 seconds...
d. Rinse hands well under running water...

Morbidity and Mortality Weekly Report
Recommendations and Reports October 25, 2002 / Vol. 51 / No. RR-16
Centers for Disease Control and Prevention...

Guideline for Hand Hygiene in Health-Care Settings
Recommendations of the Healthcare Infection Control Practices...

II. Recommendations...
F. Decontaminate hands after contact with a patient ' s intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient...
G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled...
H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care...
I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient ).
J. Decontaminate hands after removing gloves...

1. On 11/05/2020 at 10:00 AM, an observation of wound care for PI # 6 with EI (Employee Identifier) # 6, RN (Registered Nurse) # 6, 3 (North) and EI # 3, RN, Inpatient Wound Ostomy Continence Program Coordinator.

EI # 6 cleansed the sacrum, applied a Mepilex dressing, removed gloves and completed hand washing with soap and water for 6 seconds. EI # 6 failed to perform hand washing for at least 15-20 seconds with soap and water per hospital policy.

The surveyor observed 2 open (nonintact skin) abdominal wounds at different anatomical locations on the abdomen. EI # 6, RN cleansed the first wound to the right upper abdomen with theraworx foaming soap. Wearing the same gloves, EI # 6 cleansed the second wound to the lower left abdomen. EI # 6 failed to remove gloves, perform hand hygiene and don clean gloves between wounds.

After cleansing both abdominal wounds, EI # 6 removed gloves and completed hand washing with soap and water for 5 seconds and not the required 15-20 seconds.

Lastly EI # 6 performed wound care to the bilateral heels. Following the care, EI # 6 removed gloves, performed hand washing with soap and water for 6-8 seconds. EI # 6 failed to wash hands with soap and water for the minimum length of time 15-20 seconds.

After all wound care was performed, EI # 3, Inpatient Wound Ostomy Program Coordinator, repositioned PI # 6, removed gloves and performed soap and water hand washing for 10 seconds. EI # 3 failed to wash hands with soap and water for at least 15-20 seconds.

In interviews on 11/05/2020 at 11:15 AM following the above observations, EI # 6 and EI # 3 confirmed the above observations.



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2. On 11/05/2020 at 10:25 AM, surveyor along with EI # 13 CNO (Chief Nursing Officer), observed EI # 12 RN perform wound care on PI # 7.

EI # 12 washed hands with soap and water, donned gloves and sprayed foam phytoplex cleanser to sacral area and used gauze 4x4's to wipe area clean. EI # 12 removed gloves and donned new gloves without washing hands or using hand sanitizer prior to opening sterile Q-tips, measuring the sacral wound and applying venelex ointment to the wound. EI # 12 removed gloves and without washing hands or applying hand sanitizer, donned new gloves prior to applying mepilex dressing to the sacral wound.

In interviews conducted on 11/05/2020 at 11:00 AM with EI # 12 and EI # 13, the above observations were confirmed.