HospitalInspections.org

Based on review of medical records (MR), policies and procedures, and interviews with staff, it was determined the facility failed to ensure staff:

1. Followed facility policy for "Impaired Skin Integrity Plan of Care" for patients with identified pressure injuries.

2. Repositioned patients every 2 hours per policy based on Braden Assessment Score.

3. Bathed patients daily per policy based on Braden Assessment Score.

4. Performed and documented wound care per orders and policy.

5. Completed an Event Report for an Acquired Skin breakdown/ Pressure Injury.

6. Assessed wounds per policy.

7. Obtained orders for wound care.

8. Measured pressure ulcers per nursing standards.

This affected 5 of 6 MR's reviewed of patients with pressure injuries, including Patient Identifiers (PI) # 1, PI # 2, PI # 3, PI # 4, and PI # 6, and had the potential to affect all patients at risk for pressure injuries.

Findings include:

Facility Policy: NU (Nursing) Patient Admission Assessment Policy
Policy Number: None
Revision Date: 11/18/2020

Purpose:

Ensure that a thorough patient assessment is initiated on admission to the hospital.

Policy:

A. All patients admitted to the hospital will have an assessment performed by members of the healthcare team to include but not limited to:...

6. Physical Assessment...

15. Braden Scale for Skin Assessment...

D. Appropriate referrals should be requested based on assessment of patient's needs...

5. If any skin breakdown is present on admission, enter an order for Wound Care Consult in the EHR (electronic health record). The EHR system will auto enter a Wound Care referral if a Pressure Injury is documented in the Admission Assessment.

6. The EHR system will auto enter a Wound Care Referral for a Braden Score of 17 or less.

Facility Policy: NU Pressure Injury/Prevention Management
Policy Number: None
Revised Date: 2/6/19

I. Purpose:

A. Wounds in this policy do not include post-operative surgical wounds or incisions...

B. Targeted Assessment for identification of patients at risk to develop wounds and to initiate preventative skin care interventions that are key to preventing acquired wounds.

C. Prompt identification of any and all acquired pressure injury in any level of care.

D. Reduce incidence and severity of acquired pressure injury...

II. Policy

This policy applies to all inpatient nursing departments.

A. Upon admission, patients will receive a comprehensive assessment to determine their risk for breakdown. An individualized prevention and treatment plan with interventions for patients at risk or with pressure injuries will be initiated based on physical assessment findings, the Braden score and identified specific patient needs...

...C. Documentation of pressure injuries and wounds will be done utilizing the appropriate system. The pressure injuries documentation includes a description and photograph of wounds/injuries with proper patient identification. Wound staging will be completed by the physician and/or Wound Care (WC) nurse.

D. Pressure injuries should be color photographed by the assessing RN (registered nurse) upon discovery or on admission, as needed, and at discharge...

E. In the computer system, "Impaired Skin Integrity Plan of Care" will be identified on the Interdisciplinary Plan of Care, addressing interventions, goal outcomes and goal progress...

F. Pressure injury care protocols are available by stage of pressure injury...The protocols include indications for ...specialty mattresses.

III. Interventions Based on Braden Assessment Score

No risk (18 or greater) per Braden Scale Assessment:

A. Bathe daily with hospital approved body wash...

...E. Reposition at a minimum of every 2 hours, off-loading pressure points (heels, occiput, toes, sacrum, buttocks, over bony prominence's, thoracic spine, scapula, ears, between the knees), unless contraindicated.

...G. Float heels off bed with pressure-relieving heel protectors or a heel pillow...

H. Inspect skin each shift for signs and symptoms of breakdown; note any changes from previous shift assessment on appropriate form/flowsheet.

Low to High Risk (17 or less) per Braden Scale assessment:
Initiate Routine Skin Care Orders

A. Initiate Nutritional consult if order not already in system...

B. Initiate WC Nurse consult.

C. Bathe daily with hospital approved body wash, foam, or bath wipes...

E. Use hospital approved moisturizer for preventive skin care.

G. Reposition at a minimum every 2 hours, off-loading pressure points (heels, occiput, toes, sacrum buttocks, over bony prominences, thoracic spine, scapula, ears, between the knees), unless contraindicated.

H. Utilize pressure relieving devices including Air Mattress, Elbow/Heel protectors...

K. Inspect skin each shift for signs and symptoms of breakdown; note any changes from admission or previous shift assessment in the nurses' notes on appropriate form/flowsheet...

IV. Event Reporting of Acquired Pressure Injuries

A. An Event Report should be completed on any Acquired Skin breakdown or Pressure Injury that occurred while patient is in the facility or for an existing wound present on admission which fails to respond to treatment and advances or worsens...

Medical Device Related Pressure Injury:
Medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system...

VI. Physicians and nurses should utilize the EHR for placing wound care orders....

Facility Policy: NU Patient Assessment and Reassessment
Policy Number: None
Revised Date: 3/19/18

Purpose:

Establish guidelines for assessment and re-assessment of patients.

Policy:

A. Admission Assessment

1. ...The patient's Admission Assessment Part 1 should be completed and documented within 2 hours of inpatient admission. The patient's Admission Assessment Part 2 should be completed and documented within 24 hours of inpatient admission. This assessment will include advance directives...smoking status...and immunization status..., and all meaningful use objectives obtained in the admission assessment.

2. The RN is responsible for the admission assessment of the patient...

B. The initial assessment should be completed within 2 hours of admission...

C. Re-assessment

1. Each patient is reassessed when a significant change occurs in condition or diagnosis...A RN conducts reassessment at least once every 24 hours, when there is a significant change in assessment, at discharge, and/or according to unit specific policy.

Reassessment Time Frames:

Critical Care - Every 2 hours or as indicated by patient condition...

Med/Surg Unit - Every shift and as indicated by patient condition.

Facility Policy: NU Dressing Changes per Aseptic Technique Policy
Policy Number: None
Revised Date: 1/9/19

Purpose:

...to provide instructions to be followed when changing dressings using aseptic technique.

Policy:

A. Dressings should be changed ...for non-surgical wound and skin breakdown.

...C. The physician should be notified of abnormal conditions of the wound such as bleeding or signs of infection...

Procedure:

...D. Charting:

1. Condition of the wound (inspect for redness, excessive pain, ecchymosis, edema, drainage, approximation and odor.)

2. Patient's tolerance to procedure.

3. Medication used.

4. Time and date of dressing change (Note in patient's chart and on dressing.)

1. PI # 1 was admitted to the facility's cardiac care unit (CCU) from the
Emergency Department (ED) on 5/29/21 with a diagnosis of Paranoia, Psychiatric Disorder, and Tachycardia.

Review of the EHR (electronic health record) revealed at admission PI # 1 had intact skin and no pressure ulcers. The Braden Scale for Risk Assessment score was 19 with interventions to bathe daily, reposition every 2 hours, off load pressure points, float heels and inspect skin every shift for breakdown.

Review of the 6/13/21 Nursing Frequent Documentation for Patient Position revealed PI # 1 was not turned/repositioned from 7:00 AM to 8:00 PM, which was 13 hours.

Review of the 5:48 PM 6/15/21 Nursing Note revealed documentation the patient had purple pressure ulcers to bilateral outer legs/ankles and left heel, foams (dressings) and heel boots were applied. The Nursing Note further documented the buttocks was clear, foam dressing was applied for prevention, and wound care was consulted.

Review of the Wound Care Documents/Orders dated 6/17/21 12:35 PM revealed documentation pt (patient) with the following new wounds:

a. Left heel with suspected deep tissue injury (DTI), wound bed with darker black and yellow necrotic appearance, no open areas noted, no fluctuance or drainage present, erythema noted at wound edges. Recommend routine skin care with monitoring from staff, float heels on pillows when heel boots not in place.

b. Right lower extremity lateral with suspected DTI with deep purple discolored wound bed, skin sloughing noted to parts of wound bed, no drainage present. Recommend cleansing with wound cleaner, pat dry, apply duoderm gel daily, cover with foam dressing. Waffle mattress and heel boots in place at time of exam.

Review of the MR from 6/18/21 to 7/14/21 revealed no documentation of wound care to the right lower extremity lateral DTI daily as ordered.

Review of the Nursing Frequent Documentation for Patient Position 7/13/21 to 7/14/21 revealed PI # 1 was not turned and repositioned for 19 hours, from 12:00 AM 7/13/21 to 7:00 PM 7/14/21.

PI # 1 was not turned/repositioned every 2 hours per policy.

Review of the 7/15/21 4:28 AM Nursing Note documentation revealed wounds were cleaned per wound care orders, and wound care was performed. The location and condition of the wounds were not documented.

Review of the 7/15/21 12:45 PM Wound Care Documents/Orders revealed documentation of 3 new wounds to the sacrum, 2 on the right sacrum, and 1 on the left:

a. Left heel, no documentation this wound was assessed.

b. Right lower extremity lateral, no documentation this wound was assessed.

c. Sacrum, right side with 2 healing stage 2 pressure injuries, largest measuring L (length) 2 cm (centimeters) x (by) W (width) 2cm x D (depth) 0.1 cm, and more distal measuring L 0.7cm x W 0.5cm x D 0.1cm, wound beds mixed red with light yellow fibrin tissue ...no odor, periwound light pink. Recommend cleansing with wound cleanser, pat dry, apply Triad Hydrophilic Wound paste daily, may leave open to air or cover with foam dressing.

d. Sacrum left side with stage 2 pressure injury, L 0.5cm x W 0.5cm x D 0.1cm, wound bed red ...no odor, periwound area light pink. Recommend cleansing with wound cleanser, pat dry, apply Triad Hydrophilic Wound paste daily, may leave open to air or cover with foam dressing.

Further review revealed the wound care nurse educated PI # 1 on importance of turn and repositioning Q (every) 2 hours with verbalized understanding.

Review of the 7/16/21 5:00 PM Nursing Note documentation revealed, "Pt remains uncooperative with care."

Review of the 7/16/21 6:56 PM Nursing Note revealed documentation, "Pt has refused to turn off his back to be repositioned all this shift." "Re-educated pt on importance of repositioning, especially with sacral wounds, pt became agitated and started throwing bed linens in floor."

Review of the 7/17/21 7:54 PM Nursing Note documentation revealed the nurse replaced mepilex (foam) border dressings to left heel, pt had pulled off.

There was no description documented of the condition of the wound to the left heel.

Review of the Nursing Frequent Documentation for Patient Position 7/19/21 to 7/20/21 revealed no documentation of PI # 1 being turned or repositioned, which was 48 hours.

Review of the 7/21/21 Wound Care Nurse Documentation/Orders included the following wound assessments:

a. Left heel now healing stage 3 pressure injury, wound L 1.3 cm x W 0.5 cm x D 0.2 cm, wound bed red and pink and yellow sloughing, no drainage, wound edges well defined...Recommend cleansing with Vashe soaked gauze, pat dry, apply Triad Hydrophilic Wound Paste daily, cover with foam dressing.

b. Right lower extremity, lateral aspect with 2 suspected DTI, now unstageable, distal wound bed with dark brown and tan eschar, no drainage, wound edges well defined ...no odor. Recommend cleansing with Vashe soaked gauze, pat dry, apply Triad Hydrophilic Wound Paste daily, cover with foam dressing.

c. and d. Noted sacral dressing dated 7/17/21 (4 days old). Sacral stage 2 pressure injuries healed...Recommend continue with current POC (plan of care), cleansing with wound cleanser, pat dry, apply Triad Hydrophilic Wound Dressing Paste daily, may leave open to air or cover with foam dressing.

The wound care nurse also documented educating PI # 1 on importance of turn and repositioning Q 2 hours with verbalized understanding.

Review of the wound care nurse documentation on 8/5/21 revealed PI # 1 was very agitated, refused to turn for sacral assessment, and appeared to be experiencing auditory and visual hallucinations with paranoia noted. Recommended continue with current POC for sacral wound.

Review of the Nursing Frequent Documentation for Patient Position from 8/6/21 8:00 AM to 8/12/21 10:00 AM revealed PI # 1 was not turned every 2 hours for 6 days.

The surveyor requested documentation of the daily wound care to wounds at the left heel, sacrum, and right lower extremity lateral as ordered. A review of documentation from 8/6/21 to 8/30/21 in the EHR with Employee Identifier (EI) # 16, RN (registered nurse) Director of 9th floor, and Interim Director of 7th floor, revealed no documentation of wound care from 8/6/21 to 8/13/21. On 8/14/21 there was documentation in the EHR of wound care provided to the left heel and right lower extremity lateral. There was no wound care documented 8/15/21 to 8/30/21.

The nursing staff failed to follow wound care orders and document the condition of the wounds.

Review of the Nursing Frequent Documentation for Patient Position from 8/24/21 at 8:00 PM to 8/30/21 at 9:00 AM revealed PI # 1 was not turned every 2 hours for 6 days.

Review of the Wound Care Nurse Documentation/Orders dated 8/30/21 revealed:

a. Left heel, healed stage 3 pressure injury

b. Right lower extremity, lateral aspect with 2 healing stage 3 pressure injury...Recommend cleansing with wound cleanser, pat dry, apply Triad Hydrophilic Wound Paste daily, cover with foam dressing. Noted old dressing removed dated 8/23/21.

c. Right sacrum with healing stage 3 pressure injury measuring L 2.5cm x W 1.7cm x D 0.2cm, wound bed mixed red with fibrous yellow sloughing, no drainage noted, wound edges well defined and pink... Recommend cleansing with wound cleanser, pat dry, apply Triad Hydrophilic Wound Paste daily, cover with foam dressing.

d. Left sacrum healing stage 2 pressure injury measuring L 5.5cm x W 2cm x D 0.1cm, wound bed mixed red and pink with light yellow sloughing, wound edges well defined and pink...Recommend cleansing with wound cleanser, pat dry, apply Triad Hydrophilic Wound Paste daily, cover with foam dressing.

Review of nursing documentation in the EHR for dates 8/31/21 to 9/13/21 with EI # 16 revealed the daily wound care was not performed to all wounds as ordered.

An interview was conducted on 9/16/21 at 1:18 PM with EI # 3, wound care nurse, who confirmed on 8/30/21 visit, dressing to wound on right lower extremity aspect lateral had date 8/23/21 with his/her name written on it, and had not been changed for 7 days.

In an interview conducted 9/16/21 at 2:15 PM, EI # 16 confirmed wound care was not provided for all wounds, wound care was not documented per policy, and there was no documentation PI # 1 was turned/repositioned every 2 hours per policy/orders.



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2. PI # 2 was admitted 9/9/21 with diagnoses including Weakness and Lactic Acidosis.

The staff failed to assess the wounds and obtain orders for wound care at the time of admission.

Review of the Integumentary assessment dated 9/9/21 at 6:00 PM revealed the nurse documented "two wounds to coccyx area and wound to foot". There was no documentation of the description of the wounds including drainage, wound bed, surrounding tissue, odor, or measurements.

Review of the History and Physical dated 9/9/21 and signed at 10:51 PM revealed "History of Present Illness...(PI # 2) was sent to the ED (Emergency Department) by (his/her) home health nurse for evaluation of (his/her) sacral decubitus wound...(spouse) also reports a wound on (his/her) back and some small skin tears on (his/her) thighs".

Review of the physician orders dated 9/10/21 at 9:03 PM revealed an order to consult Wound Care Nurse. There was no order for wound care.

Review of the Integumentary documentation notes from 9/10/21 through 9/13/21 revealed the foam dressing was clean dry and intact. There was no documentation of wound care being provided.

Review of the Wound Care Consult completed on 9/14/21 at 1:30 PM revealed the following wounds:

1. Left sacrum Stage 2 pressure injury 1.8 cm (centimeters) x 2 cm x 0.2 cm (length x width x depth). Recommend cleansing with wound cleanser, pat dry, apply Triad Hydrophilic Wound Dressing Paste daily, cover with foam dressing, to be changed daily and prn (as needed).

2. Sacrum midline unstageable pressure injury measuring 3 cm x 2.5 cm (length x width) wound bed with soft brown and tan eschar. Recommend cleansing with wound cleanser, pat dry, apply Triad Hydrophilic Wound Dressing Paste daily, cover with foam dressing, to be changed daily and prn (as needed).

3. Healing surgical wound to back with open are measuring 7 cm x 1 cm x 0.5 cm. Recommend cleansing with wound cleanser, pat dry, apply Triad Hydrophilic wound dressing paste daily, may leave open to air.

4. Left forearm with healing skin tears x 2. Recommend cleansing with wound cleanser, pat dry, cover with Oil Emulsion gauze, gauze and Bulkee wrap, to be changed daily and prn.

5. Right forearm with 2 skin tears, category 2 and 3. Recommend cleansing with wound cleanser, pat dry, cover with Oil Emulsion gauze, gauze and Bulkee wrap, to be changed daily and prn.

6. Right heel Stage 1 pressure injury. Recommend routine skin care with monitoring from staff.

7. Left lower extremity, pretibial area with circular healing wound. Recommend routine skin care with monitoring from staff.

In an interview conducted on 9/16/21 at 2:50 PM with EI # 1, Chief Quality Officer, and EI # 5, Director Med Surg unit, EI # 1 confirmed the wounds were not assessed and documented per policy and wound care orders were not obtained at the time of admission.



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3. PI # 3 was admitted to the hospital on 8/30/21 with the diagnosis of Edema and Altered Mental Status.

Review of the 8/30/21 admission comprehensive assessment revealed the Braden Score of 10 (which is at high risk for developing pressure injuries) and the patient had a pressure ulcer. There was no documentation of a description, location, or photograph of pressure injuries present on admission.

Review of the 8/31/21 nursing documentation revealed no documentation or photograph of any wounds.

Review of the 9/1/21 wound nurse consult revealed documentation the left heel had a suspected deep tissue injury. He/she described this wound as a pressure ulcer with eschar, which would have made this an Unstageable Pressure Injury. The wound nurse failed accurately describe/ identify the wounds.

Review of the 3 Wound Care Documents (orders) dated 9/1/21 revealed the following documentation:
"1. Left Upper Forearm, ...Recommend routine skin care (which includes turning every 2 hours), cover blister filled areas with Oil Emulsion Gauze, cover with gauze and Bulkee wrap, to be changed daily and PRN (as needed), elevated LUE (Left Upper Extremity) on pillow.

2. Left Heel with suspected deep tissue injury (DTI), deep purple maroon discoloration and sanguineous filled blister area with pinpoint spontaneous ruptured opening, periwound area with dryness and flaking. Recommend routine skin care, cover blister filled areas with Oil Emulsion Gauze, cover with gauze and Bulkee wrap, to be changed daily and PRN. Float heels on pillows.

3. Right Foot lateral surface with unstageable pressure injury with suspected deep tissue injury, wound bed mixed red with black eschar center, light purple discoloration surrounding eschar area, with light sanguineous drainage, periwound area with severe dryness and flaking. Recommend cleansing with wound cleanser, pat dry, apply Medihoney Gel, gauze and Bulkee wrap to be changed daily and PRN.

Sacrum and buttocks with healed scarred areas, skin intact. Will order waffle mattress for placement."

Review of the 9/1/21 photographs of Left Upper Forearm, Left Heel, and Right foot wound revealed a gauze pad package labeled with a patient sticker. There were no measurements (m/m) of the wounds that contained length (L)/width (W)/depth (D).

Review of the nursing notes dated 9/3/21, 9/6/21, 9/8/21, 9/9/21, 9/10/21, and 9/11/21 revealed no documentation wound care had been performed daily as ordered.

Review of the 9/11/21 Wound Care Document revealed documentation, "Wound care asked to see patient due to right groin CVL (Central Venous Line) removal and open wound.
Right groin Stage 3 pressure injury related to a medical device, 1.5 cm X (times) 2.2 cm X 0.3 cm wound bed with loose brown necrotic tissue and light-yellow sloughing, no drainage noted, wound edges pink with light maceration, periwound area with induration noted and multiple scatter raised lesions with induration noted, no drainage noted to palpation the site. Recommend cleansing with wound cleanser, pat dry, cover with Xeroform Gauze, gauze and tape dressing."

Review of the 9/12/21 and 9/13/21 nursing documentation revealed the right groin wound were not assessed or wound care provided.

Review of the MR revealed no documentation personal care (bath/pericare) had been provided for PI # 3, a bed bound/total care patient, for the following days: 9/8/21, 9/10/21, 9/11/21, 9/12/21, and 9/13/21. The staff failed to follow policy for patient with a Braden Assessment score of less than 17 to prevent pressure injuries.

Further review of nursing notes dated for 8/30/21 to 9/14/21 revealed no documentation the patient was turned every 2 hours per policy with a Braden Assessment score of less than 17.

During an observation of wound care with EI # 3, RN on 9/14/21 at 9:45 AM, on entry to the room the surveyor observed PI # 3 was in a supine position and the air mattress was deflated. There was no pump control for the air mattress or wedge for turning in the patient's room. The turn schedule on the wall indicated the patient should be on left side. PI # 3 also had 3 new pressure injuries to right ear and right chest. The surveyor also noted PI # 3's skin was very dry and flaky. EI # 3 confirmed all of the above findings.

Review of the 9/14/21 Wound Care Documents/Orders revealed 3 new Stage 2 Pressure injuries: Right Chest, Right Ear proximal, and Right Ear lower pinna.

In an interview conducted on 9/17/21 at 1:30 PM, EI # 4, Director of Clinical Informetics, confirmed the staff failed to document complete assessments of wounds, photograph wounds per policy, perform ordered wound care, bathe and turn to the bedbound patient per policy.

4. PI # 4 was admitted to the facility on 6/13/21 with the admitting diagnosis of Pneumonia.

Review of the 6/13/21 admission nursing documentation revealed the patient had a pressure ulcer, open draining wound and the Braden Score of 12.

Further review of the 6/13/21 admission nursing documentation revealed no photograph, location or description of the pressure ulcer or open draining wound.

Review of the 6/15/21 wound care consult/ orders revealed "Noted Suspected Deep Tissue Injury to sacral and bilaterally to buttocks, deep purple discoloration with areas of shearing, periwound area with darker brown pigmentation but no issues noted. Recommend cleansing with soap and water, pat dry, apply Barrier cream TID (3 times a day) and PRN with turning and repositioning Q 2 hours. Will order waffle mattress for placement." There were no m/m of the wound.

Review of the list of All Orders revealed 6/15/21 at 10:32 AM Wound Care Routine: Daily, Sacrum/Buttocks-Recommend cleansing with soap and water, pat dry, apply Triad Hydrophilic Wound Paste daily, may leave open to air.

Review of the Communication Orders dated 6/15/21 at 10:32 AM revealed Order Comment: "Routine 1 (every 12 hours).
1. Apply Mepilex Heel foam dressing to heels.
2. Apply Mepilex Border dressing to elbows.
3. Mepilex Border Sacrum to sacrum and coccyx to minimize friction and shear.
PULL DRESSING BACK AND ASSESS SKIN EVERY SHIFT."

There was no documentation the staff assessed patient heels and elbows for the Mepilex dressing.

The surveyor asked EI # 6, Director 6th floor, "Did wound care nurse measure the DTI to buttocks/ sacrum? Which order to the buttocks are the staff to follow?" EI # 6 replied, "There were no measurements. I'm not sure which orders."

Review of the 7/13/21 Wound care follow up note/ orders revealed, "Noted increase in shearing with the largest area on right buttocks with yellow sloughing noted to wound bed, no drainage, periwound area with light pink epithelia tissue with darker pigmentation as previously charted. Recommend cleansing with soap and water, pat dry, apply Triad Hydrophilic Wound Paste daily, may leave open to air or cover with foam dressing. Will order waffle mattress for placement, turn and reposition every 2 hours. Wound care provided and Triad left in patient room."

There was no documentation of the measurements of the open areas, how much of the shearing had increased.

Review of the 7/13/21 photographs of buttocks and sacrum revealed 4 open areas (Stage 2 - Stage 3 pressure injuries).

Review of the 7/21/21 Wound care document/orders revealed, "Wound care follow up for Shearing to sacrum and right buttocks area... Noted healing with largest area on right buttocks improved, yellow fibrin noted to wound bed, light serous drainage, ...noted slight increase in periwound erthema. Recommend continue with current POC (Plan of Care)... Waffle mattress in place and needs air added, no pump available... RN in room will obtain pump and inflate (Waffle mattress). Turn and reposition Q 2 hours.

Noted left heel with suspected deep tissue injury, skin intact, deep purple/maroon discoloration periwound with bright blanchable erythema...

Noted healing medical device related, unstageable healing wound to nose, believed to be from Bipap mask, wound bed with thick black scabbing, no drainage... Apply Mepilex foam to protect additional breakdown before applying Bipap mask..."

There were no measurements documented for any of the wounds.

Review of the 7/21/21 photographs revealed more open areas on buttocks, and Unstagable pressure injury to left heel.

Review of the 9/10/21 Wound care follow up/orders revealed, "...Noted left heel with healing Stage 2 Pressure injury, slight increase in size... Recommend cleansing with wound cleanser, pat dry, apply Triad Hydrophillic Wound Dressing Paste daily, cover with foam dressing, float heel on pillows. Noted old dressing removed dated 9/6/21..."

Review of the 9/10/21 photograph revealed left heel dressing with the following documentation, "9/6/21 LW 1755"

Review of the MR revealed the staff failed to assess, clean wound, provide wound care from 9/6/21 to 9/10/21.

Review of the MR revealed no documentation PI # 4 was bathed based on the Braden Assessment score below 17 for the dates of 6/17/21, 6/21/21, 6/22/21, 6/25/21, 6/26/21, 6/27/21, 7/2/21, 7/4/21, 7/5/21, 7/6/21, 7/8/21, 7/10/21, 7/11/21, 7/16/21, 7/17/21, 7/19/21, 7/20/21, 7/26/21, 7/28/21 to 8/2/21 (which was 5 days), 8/3/21, 8/5/21 to 8/14/21 (10 days), 8/17/21 to 8/21/21 (which was 5 days), 8/22/21, 8/23/21, 8/25/21 to 8/28/21 (which was 4 days), 8/29/21 patient refused, the next bath documented was on 9/6/21 was 7 days later.

In an interview conducted on 9/16/21 at 3:30 PM, EI # 15, Orthopedic Coordinator, LPN (Licensed Practical Nurse), confirmed the staff failed to assess/ measure/ photograph/ provide bath daily per policy, Braden Score Assessment and nursing standards.

5. PI # 6 was admitted to the facility on 9/5/21 with diagnoses including Altered Mental Status and Sepsis.

Review of the 9/5/21 admission nursing documentation revealed PI # 6 had a pressure ulcer and open/draining wound. There was no description, measurements, or photograph of the wounds.

In an interview conducted on 9/16/21 at 2:35 PM, EI # 6 confirmed the nurse failed to follow facility policy for wound management.

Based on observations, review of facility policies and procedures and interview with the staff it was determined the facility failed to ensure the staff:

1. Performed hand hygiene / hand washing with glove changes.

2. Disinfected re-usable medical equipment after performing patient care

This affected 3 of 3 patient observations on hand hygiene including Patient Identifier (PI) #3, PI # 2, PI # 1, and had the potential to negatively affect all patients served by the facility.

Findings include:

Facility Policy: NU (Nursing) Dressing Changes per Aseptic Technique Policy
Policy Number: None
Revised Date: 1/9/19

Purpose:

...to provide instructions to be followed when changing dressings using aseptic technique.

Policy:

A. Dressings should be changed ...for non-surgical wound and skin breakdown.

Procedure:

A. Preparation:

...5. Wash hands

B. Assemble and prepare supplies needed.

1. Clean gloves

...4. Red bio-hazard trash bag

C. Procedure:

1. Apply clean gloves and remove soiled dressing. Discard soiled dressing and gloves in red bio-hazard bag.

2. Wash hands.

3. Apply clean gloves.

4. Clean wound with physician ordered cleansing solution...

5. Remove gloves.

6. Apply clean dressing...

7. Repeat steps E through J (1-6) for each separate wound.

...9. Assist patient with clothing and reposition for comfort.

10. Remove gloves.

11. Wash hands...

Facility Policy: Equipment Cleaning: Low Level Disinfection Policy
Revision Date: 6/27/21

Introduction
To ensure proper cleaning/ disinfection (low level) of patient care medical equipment and to maintain proper cleanliness of patient ready medical equipment...

Once equipment is cleaned... In patient care areas, clean equipment may remain in the room, but is to be covered once cleaned...

1. PI # 3 was admitted to the facility on 8/30/21 with the admitting diagnosis of Altered Mental Status.

On 9/14/21 at 9:45 AM the surveyor observed Employee Identifier (EI) # 3, Registered Nurse (RN), perform wound care on PI # 3, who was bedbound.

EI # 3 performed hand hygiene and applied gloves upon entry to patient's room and removed a blood pressure cuff from right arm that was left on patient. EI # 3 removed scissors and telephone/ camera from her pocket and placed on a towel white towel that was on the over bed table.

EI # 3 used scissors to cut dressing from right foot replaced the scissors to over bed table, removed gloves, applied clean gloves and failed to perform hand hygiene after removing the dirty gloves.

EI # 3 cleaned the wound with wound cleanser removed gloves and applied clean gloves and failed to perform hand hygiene. EI # 3 removed the telephone/ camera from over bed table and took a photograph of right foot, removed gloves and re-applied clean gloves and performed wound care. EI # 3 removed gloves, applied clean gloves and failed to perform hand hygiene after removing dirty gloves.

EI # 3 removed dressing from right groin removed gloves, applied clean gloves and failed to perform hand hygiene when removing dirty gloves. EI # 3 placed telephone/ camera on the patient's bed then cleaned the wound, removed gloves and applied clean gloves, picked up telephone from patient's bed took photograph and replaced to bed side table. EI # 3 removed dirty gloves, applied clean gloves and failed to perform hand hygiene after removing gloves.

EI # 3 completed wound care for the 3 other wounds then placed the dirty scissors and telephone in pocket and failed to clean the re-useable equipment.

In an interview conducted on 9/16/21 at 2:30 PM, EI # 1, Chief Quality Officer(CFO) confirmed EI # 3 failed to perform hand hygiene and clean equipment after use.




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2. PI # 2 was admitted on 9/9/21 with diagnoses including Weakness and Lactic Acidosis.

On 9/14/21 at 1:35 PM an observation of wound care by EI # 3, RN, was conducted. After cleaning, EI # 3 removed gloves then donned new gloves and applied Triad cream to wound and surrounding area with finger of glove.

EI # 3 then removed gloves then donned gloves and continued to apply Triad Cream to another wound on PI # 2 back.

EI # 3 failed to perform hand hygiene after removing gloves per facility policy.

In an interview conducted on 9/16/21 at 2:30 PM, EI # 1 confirmed EI # 3 failed to perform hand hygiene per facility policy.



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3. PI # 1 was admitted to the facility on 5/29/21 with a diagnosis of Paranoia, Psychiatric Disorder, and Tachycardia.

On 9/14/21 at 11:34 AM the surveyor observed EI # 3 perform wound care on the bed bound patient, and the following observations were made:

a. EI # 3 entered room, pulled phone from pocket to pull up the patient's chart, and donned gloves without performing hand hygiene.

b. EI # 3 removed the old dressing to wound at right heel, changed (doffed and donned) gloves without performing hand hygiene, then removed old dressing to left heel, took picture of wound with phone, changed gloves without performing hand hygiene. EI # 3 then turned PI # 1 to left side, removed old dressing to sacrum, used phone to take picture of wound, measured the wound, used phone to take a second picture, scratched the patient's back per his/her request all while wearing same gloves. Then, still wearing same gloves, applied cream/lotion to back and commented, "Oh, I got a hole in my glove from scratching him/her." EI # 3 then changed gloves, without performing hand hygiene and applied triad paste to scrotum and inner thighs, picked up phone and took picture of scrotal area and penis wound. EI # 3 then doffed gloves, performed hand hygiene, and left the room to obtain new wound supplies.

c. EI # 3 entered room, performed hand hygiene, and donned new gloves to begin wound care. EI # 3 cleansed and dressed wounds to right heel, left upper chest, bridge of nose, left ear pinna, and sacrum, changing gloves after each cleansing and again after each dressing applied without performing hand hygiene.

d. During the time of observation, the phone utilized by EI # 3 to take pictures of the wounds was noted in EI # 3's pocket, laid on top of the IV pump, placed on a kleenex on the patient's bedside table, and back to pocket. Gloves were changed without performing hand hygiene after touching phone.

e. After wound care was completed, EI # 3, wearing gloves, made sling to elevate scrotum. While wearing same gloves, EI # 3 gathered supplies not used during wound care, and placed them back in the patient's room, doffed gloves and then performed hand hygiene upon exiting room.

EI # 3 failed to perform hand hygiene after removing gloves per policy.

In an interview conducted on 9/16/21 at 2:30 PM, EI # 1 confirmed EI # 3 failed to perform hand hygiene.