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Based on interview and record review, the facility failed to assess and document the skin condition for one patient (P-10) of ten patients reviewed, resulting in inconsistent and missed nursing assessments. Findings include:

On 6/20/24 record review for P-10 revealed that she was an 18-year-old female admitted to the facility on 6/7/24 with a chief complaint of lower left popliteal fossa wound (pressure injury behind her left knee due to brace). Patient had a history of spastic cerebral palsy and quadriplegia. Also, patient recently underwent left hip Girdlestone procedure (removal of femoral head and neck) on 5/2/24.

Nursing admission assessment dated 6/8/24 0000 indicated patient had "Wound, pressure ulcer, Stage I".

Infectious disease practitioner note dated 06/08/24 0936 had the following documented. Integumentary: Left posterior knee with two-inch linear ulcer down to subcutaneous skin with slight bleeding and pus with malodorous smell. Further in the note under Impression and Plan Consultation: Diagnosis: Left popliteal fossa ulceration, abrasion and infection associated with contact injury from orthotics. Decubitus ulcer of lower extremity, Stage 2. Please consult wound care for proper management of dressing changes.

Wound care nursing note dated 6/10/24 1050 revealed: Consulted for wound on left leg. P-10 had surgery on the left hip about 5 weeks ago. Per her mother patient was not to remove the brace until she had a follow up visit with ortho (orthopedic surgery). During this time patient developed a wound on the back of her left knee. Measurements 8 x 3 x 0.1cm with dark red base, tendon noted, Stage 3 Pressure injury. Will dress the wound with Aquacel AG (a silver impregnated antimicrobial dressing for various types of wounds), foam and wrap.

Further record review for P-1 revealed no nursing wound assessments for the day shifts on 6/14/24 and 6/15/24. There was no staging assessment for patient's pressure injury in nursing assessments after wound care had consulted on 6/10/24 till discharge.

Wound care consult notes dated 6/11/24, 6/12/24, 6/13/24, 6/14/24, and 6/17/24 had no pressure injury staging information recorded.

On 6/20/24 at 1115 wound care nurse, Staff O, was interviewed over the phone. Staff O was asked to describe if during her assessment of P-10 she could visualize the tendon in the bed of the wound. Nurse stated "no". She added that patient had severely contracted extremities and the area behind patient's left knee was hard to visualize. Therefore, nurse palpated it slightly and felt the tendon structure. Based on her findings she staged the pressure injury as Stage 3 during her initial assessment on 6/10/24.

Facility's policy Skin and Wound care was requested and reviewed on 6/20/24. Policy dated 7/21/2021 indicated:
"I. Objective
To provide guidelines for skin and wound care.
II. Scope
Registered Nurse (RN) and other patient care providers within their scope of practice.
III. Policy
A. The RN is responsible for the assessment, planning, evaluation and documentation of skin and wound care. Wounds are assessed with each dressing change and characteristics documented in the medical record.
B. Wound care is provided using [facility name] Wound and Skin Care Flow Charts as guidelines for the RN to independently make decisions and initiate orders for wound care."

Facility's policy Patient Assessment and Documentation was requested and reviewed on 6/20/24. Policy dated 02/23/2022 indicated:
"I. Objective
To provide patient assessment and documentation guidelines of nursing care for patients with inpatient status.
III. Policy
B. The RN documents patient information in the electronic medical record (EMR) except when such documentation is outside of the scope of existing electronic forms or during system downtime time when downtime procedures will be followed.
C. The RN documents admission and on-going and focused assessments, patient/family teaching, plan of care, interventions and patient response in the medical record. The RN documents all pertinent patient data, including but not limited to, designated required fields.
D. The RN is responsible for patient assessment, data interpretation, determination of patient needs, establishment of nursing intervention priorities, and evaluating effectiveness of the plan of care.
C. Ongoing Assessment
1. An Ongoing Assessment is conducted minimally once every 12 hours and includes but is not limited to fall risk, self-harm risk, need for restraints and need for continuous observation. The Physical Assessment includes a core assessment of all systems with consideration to deviation from normal and special attention to new onset variance or change in degree of variance."

Based on observation, interview, and record review, the facility failed to ensure that clinical staff followed the policy for medication administration and handling for two patients ( P-2 and P-3) of 10 patients reviewed, resulting in expired and innapropriately stored medications in inpatients' rooms, and potential negative outcomes for the patients. Findings include:

On 6/18/2024 at 1042, during a tour of the Pediatric Intensive Care Unit with Nursing Administrative Director, Staff E, and Regulatory Manager, Staff D, a bag of dialysate, 2.5% Dianeal with 2.5% Dextrose and additives, 2,000 mL was hanging on a hook on the wall in the patient's room 5P03. The bag had an expiration date of 6/14/2024 at 1400. PICU Nurse, Staff M, was asked about the medication and stated that the bag was left in the patient's room from the previous shift.

On 6/18/2024 at 1110, room 5P02 was observed. In the corner on the ledge of the window, there were five unopened medications present: three vials of Albumin 25% for injection, Atropine 1 mg/10 mL for injection, and Calcium Chloride 1 gm /10 mL for injection. Nurse Manager Staff L acknowledged the findings.

On 6/20/2024 at 1435, during interview with CNO, Staff B, she was asked if her expectations were for the clinical staff to follow facility's policies and procedures. Staff B responded "yes."

On 6/20/2024 at 1400, policy 2 MED 500 Medication: Orders, Administration, and Documentation, dated 11/1/2023 was reviewed. Policy indicated, "Only medications that are due to be administered during the current medication administration are brought to the point of care."

On 6/20/2024 at 1405, policy 2 MED 101 Medication Storage and Handling, dated 8/24/2023 was reviewed. Policy indicated "All outdated or unused medications, as well as medications in containers with work, illegible, or missing labels, are returned to the Pharmacy for segregation and disposition. The policy also indicated that "All medications removed from a medication storage area must be removed just prior to administration and for only a single patient at a time. Multidose vials must be stored outside of the immediate patient treatment area. Once removed, the medication must remain with the authorized individual at all times and should not be left unattended in a non-secure area. If not administered, the medication is returned to a secure storage.

Based on observation, interview and record review, the facility failed to survey and maintain a clean and sanitary environment as part of an Infection Prevention and Control program, including maintaining surfaces clean, intact, free of dust and debris, for a census of 133 patients, resulting in the potential for spread of infection, and unclean environment, which could result in transmission of infection. Findings include:

During the initial tour of the facility on 6/18/24 at 1042, the environment was observed for cleanliness.
Upon inspection of room #277 on Pediatric Intensive Care Unit (empty and ready for a new patient) two computers on wheels were observed in the room. High dust was found on the light above the head of the bed, closet, and electronic equipment. Dust also was found on the windowsill and the bases of the both computers on wheels.

Further observation was conducted in the room #226, which was ready for a new patient. It had high dust on the equipment and substantial amount of dust on computer on wheels.

Nurse Manager, Staff L, was present during the tour and was asked how often rooms are cleaned. Nurse stated that rooms are cleaned daily and after patients' discharge.

Later during the tour, on 6/18/24 at 1212, room #630 was observed on a different unit. It had a couch mattress with approximately 6-inch tear. High dust was found on equipment and windowsill.

Policy Infection Control in the Environment of Care, Dated 1/4/21, was reviewed and indicated:

Routine Patient Room Cleaning
B. All horizontal surfaces including floors, bed rails and tabletops are cleaned with the facility's approved Disinfectant on a daily basis.

4. Bedside Computers, Handled Devices and Bar Code Scanners.
D. Bedside computers, handheld devices and bar code scanners must not be stored in a patient's room, except if it is designated equipment for a patient in Contact or Contact Plus Precautions.
G. Bedside computers, handheld devices and bar code scanners will be cleaned with facility's approved disinfectant wipes on a weekly basis, when visibly soiled, if contaminated with blood or body fluids and upon exit from an isolation room.

Based on observation, interview and record review, the facility failed to ensure that clinical staff had appropriate infection control education with practical applications of infection prevention and control guidelines, policies, and procedures, resulting in inconsistent hand washing practices and the potential for adverse patients' outcomes. Findings include:

During the initial tour of the facility on 6/18/24 at 1042 the environment was observed for cleanliness; staff was observed providing direct patient care.

Each patient room was noted to have hand hygiene staff reminder signs placed directly on the doors. Signs indicated importance of the hand hygiene upon entrance to the patient room and after providing care.

Approximately at 1050 on 6/18/24 Staff registered nurse (RN), Staff M, was observed coming to patient's room, picking up medications, approaching patient's bed and touching equipment without prior hand hygiene. Same nurse was observed in a different room while monitoring patient, and touching equipment without prior hand hygiene upon entrance to the room.

At 1127 on 6/18/24, Staff RN, Staff N, was observed during direct patient care in room 216. Nurse was wearing gloves while providing care for the patient. Staff N took off the diaper and placed it on the side of the crib. She cleaned patient with a wipe and placed it on the diaper. Nurse applied a clean diaper while wearing the same gloves. Further, Staff N covered patient with a plastic bear hugger blanket (warming device), and covered it with a colorful crochet blanket, while wearing same gloves. Then she pressed the button (with her right hand) on the bear hugger machine to inflate the warming blanket. Afterwords, nurse proceeded to roll the used diaper (with both hands) and discarding it into trash bin. Right after, she approached the patient's bed, adjusted breathing corrugated tubing and central lines, while still wearing the same gloves. After adjusting equipment and making sure patient was safe and comfortable nurse took the gloves off and proceeded to wash her hands in a sink. Staff N was queried immediately after she washed her hands regarding her hand hygiene practices. Nurse stated that she would change gloves if the diaper was soiled with stool. This diaper only had urine in it, and she also was mindful to keep her left hand clean wile changing the patient.

At approximately 1200 P-4's family was interviewed in room #563-1. During interview multiple staff was noted entering the room. No hand hygiene was noted by one staff nurse who brought supplies in (to start new IV access) and the other staff who came in to assist.

On 6/18/24 at approximately 1340 P-1 was interviewed in her room. Patient stated that she gets admitted to facility often due to her condition. This is the facility that she always comes to. P-1 was asked if clinical staff consistently performs hand hygiene. Patient stated that some nurses better than the others. Sometimes nurses don't apply foam sanitizer before they don gloves and provide care. Also, patient added, that some nursing staff don't wear gloves while touching the IV equipment.

Facility policy was requested and reviewed on 6/18/24. Hand Hygiene Policy, dated 11/01/23, indicated:

Objective/Purpose.
I. To prevent the transmission of microorganisms from person to person in all health care settings.
III. Policy.
Hand hygiene is the single most effective method to reduce the transmission of infection. Hand hygiene with soap and water must be performed for at least fifteen seconds with friction or hand hygiene with alcohol-based hand rubs must be performed for ten seconds. An antimicrobial product must be used for hand hygiene prior to surgery or invasive procedures. For general patient care regular (non-antiseptic) soaps or alcohol-based handrubs are adequate. All [facility name] department managers are responsible for enforcing hand hygiene compliance.

IV. Procedure and/or Provisions.
B. Indications for hand hygiene are:
1. Upon patient room entry and exit.
2. Before having direct contact with patients.
3. Before donning sterile and exam gloves.
4. Prior to the insertion of invasive devices (e.g. indwelling urinary catheters, peripheral IV catheters).
5. Before and after dressing changes.
6. Between clean and contaminated tasks on the same patient.
7. After care of the patient including contact with the patient's intact skin
8. After contact with a source of microorganisms (body fluids, secretions, excretions, mucous membranes, non-intact skin)
9. After contact with equipment or surfaces likely to be contaminated, including bed rails, bedside trays, telephones, and other objects in the patient's immediate environment.
10. After contact with face, nose, hair, contact lenses, etc.
11. After toilet use.
12. Before and after eating.
13. After removing gloves.