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Based on document review and interview, it was determined that for 1 of 3 (Pt #2) clinical records reviewed for pressure ulcers, the Hospital failed to ensure that the nursing staff properly assessed a newly hospital acquired wound by not staging the wound and taking photographs of the wound, as required.

Findings include:

1. The Hospital's policy titled, "Core: Wound Care Team Assessment" (dated 6/2020), was reviewed on 9/16/2020, and required, "This procedure establishes guidelines for the wound care team's role in initial and routine patient skin and wound assessments...2. Wound Care Coordinator or Wound Care RN performs BWAT (Bates-Jensen Wound Assessment) for...a new wound...Pressure ulcers are staged according to PUPA [National Pressure Ulcer Advisory Panel] guidelines. 5. Wounds photos are obtained according to policy..."

2. The clinical record for Pt #2 was reviewed on 9/14/2020. Pt #2 was admitted on 12/12/19 with respiratory failure and anoxic encephalopathy (brain damage). Pt #2's initial wound assessment, documented by the Wound Care Nurse (E # 3), dated 12/13/19, included, "Pressure injury: L[eft] great toe(s). Wound onset type: Present on admission." The clinical record included documentation of one wound upon admission.

- The Nursing Notes (dated 12/13/19) included that Pt #2's Braden Score (pressure ulcer screening tool) was documented as 9 (indicating high risk for skin breakdown).

- Pt #2's Plan of Care, initiated 12/13/19, included, "Impaired skin/tissue integrity: Desired outcome: Healable wound goal ..."

- A subsequent wound assessment (dated 1/3/2020), documented by the Wound Care Nurse (E #4), included, " ...L[eft] buttock. Wound onset type: Acquired After Admission. Wound length: 1.2 cm. Wound width: 1.3 cm. Wound depth: 0 cm." The wound assessment for Pt #2's newly acquired (left buttock) pressure ulcer lacked staging and photographs of the wound, as required.

3. On 9/17/2020 at approximately 9:30 AM, an interview with the Wound Care Coordinator (E #5) was conducted. E #5 stated that new wounds should be staged, and there should be photographs taken. E #5 reviewed Pt #2's clinical record and confirmed that there was no photograph of the left buttock wound and that the wound was not staged.

Based on document review, observation, and interview, it was determined that for 4 of 4 staff (E#9, E#11, E#14, and E#15) observed providing direct patient care, the Hospital failed to ensure that staff used gloves properly and performed hand hygiene after removing gloves, to prevent and control the transmission of infection.

Findings include:

1. The Hospital's policy titled, "Hand Hygiene" (dated 6/2018) was reviewed on 9/15/2020, and required, "This procedure establishes guidelines for hand washing. To prevent the spread of infection. The policy of [Hospital] is to ensure the following:...3. Additional Opportunities for Hand Hygiene: g. Before donning and after removal of gloves..."

2. During an observational tour of the 2nd Floor Medical Unit at the Hospital's 2nd Campus, at approximately 11:10 AM, two Registered Nurses (E#14 and E#15) were providing incontinence care and a bed bath for a patient. Both E#14 and E#15 were double gloved. E#14 began wiping the patient down with cloths, going from head to toe and doing perineal care. After wiping the patient down, E#14 then went to grab a clean towel to dry the patient from head to toe with the same pair of gloves on. E#14 then removed the top layer of gloves and held them in her hand as she went to retrieve lotion from the supply drawer. E#14 discarded the used gloves in her hand, went to grab a new pair of gloves and put them over the pair she was wearing. E#14 applied cream to the patient's perineal area, then changed the top layer of gloves. E#14 then went to wipe the patient's nasal cannula/oxygen tubing. E#14 did not perform hand hygiene after each glove removal.

3. On 9/14/2020 at approximately 11:45 AM, on the 3rd Floor's High Acuity Unit, Pt #6's tracheostomy care, with the Respiratory Therapist (E #9) was observed. Prior to Pt #6's tracheostomy care, E #9 donned two pairs of gloves. E #9 proceeded to remove Pt #6's tracheostomy neck ties and then removed the first pair of gloves. E #9 removed the drain sponge from E #6 and then removed the 2nd pair of gloves. E #9 then donned another pair of gloves and applied a new drain sponge around Pt #6's tracheostomy site. E #9 failed to perform hand hygiene after removing the first two pairs of gloves.

4. On 9/15/2020 at approximately 9:45 AM, on the 4th floor Medical/Surgical Unit, incontinence care for Pt #10, performed by the 4th Floor CNA (E #11), was observed. Prior to Pt #10's incontinence care, E #11 donned two pairs of gloves. E #11 removed Pt #10's soiled incontinence pad and then proceeded to clean the patient's perineal area. E # 11 removed the first pair of gloves after cleaning the perineal area. E #11 did not perform hand hygiene after removing the first pair of gloves. E #11 stated that he wears two pairs of gloves when performing patient care.

5. On 9/14/2020 at 11:00 AM, an interview was conducted with the Registered Nurse (E#14). E#14 stated that she double gloves for extra protection in case the gloves tear.

6. On 9/15/2020 at 10:00 AM, an interview was conducted with the Director of Quality (E #12). E #12 stated that it is not standard practice to "double glove" when performing patient care. E # 12 stated that staff should wear one pair of gloves, take them off in between tasks, and wash their hands.