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Based on chart reviews and interviews the facility failed to have processes in place to protect patient # 1 from device related injuries (DRIs). Nursing failed to ensure patients were properly assessed and/or reassessed for wounds. The facility failed to follow their own policies and procedures for turning and repositioning patients, in 1 of 1 (patient # 1) charts reviewed.

Review of the patient # 1 chart revealed she was admitted to the facility on 6/4/22 for sepsis and unresponsiveness. Review of the chart revealed that upon arrival to the emergency department on 6/4/22, patient # 1 was unable to breathe on her own and was placed on a ventilator. Patient # 1 was intubated with endotracheal tracheostomy tube (ETT) (tube placed in the trachea or airway to breathe for a patient that has a compromised airway). ETT requires a tube tamer (device used to secure ETT to patient for airway management or to breathe/assist with breathing on ventilator) to secure device. The facial tube tamer secures to ETT and wraps around back of head/neck, then Velcro's to itself across the ears. Review of patient # 1 chart revealed that there was no found documentation of wound prevention from ETT and its securement device.

Review of the nurses notes on 6/9/22 the nurse documented that patient # 1 had identified a skin breakdown to the left cheek of her face after turning patient # 1 from stomach to her back. Review of the nurses' notes revealed that no physician was notified of the injury at that time. There were no found nurses assessments documented concerning the wound(s).

Review of the nurses' notes dated 6/7/22 at 1042 revealed the patient was placed on their stomach and not turned until 6/9/22 at 1420. Review of the nurses note revealed a request for wound care consult on 6/14/22. Review of nurse's notes dated 6/14/22 revealed worsening condition of wound to left face cheek and chin/lips. The chart displayed pictures of an extensive injury to the left cheek with black dead tissue due to prolonged pressure from the ETT, tube tamer, or no preventative measures. Review of the policy and procedure, "prone positioning protocol/COVID-19 resources," D. 15. " .... make sure that tubes and equipment are not under patient, to avoid skin breakdown and compression from devices." D. 16 "reposition body, extremities, and head every 2-4 hours to minimize risk of skin breakdown and edema. Assess skin, if possible, for areas of redness and breakdown." The was no found nursing documentation that patient # 1 was turned every 2-4 hours per facility policy. Review of the chart revealed patient # 1 was in the prone (laying on her stomach) position for greater than 48 hours.

COVID-19 resources attached to prone policy E. 8 (no date or revision on this policy) states "reassess position and function of all lines and tubes." E. 9 states "reassess skin to evaluate pressure areas, identifying areas for alternate padding before returning patient to prone position." Documentation is not consistent for this patient as evidenced by the development of a large unstageable pressure ulcer from a device to the left cheek.

Review of physician/ wound consult orders dated 06/14/22 revealed a new order for wound care with moist gauze and tape, on 6/15/22 the wound care order was changed to Santyl (Santyl is a chemical enzyme debridement agent utilized to assist in the removal of necrosis or eschar) application daily. Patient # 1 received one treatment of Santyl to the left face cheek wound prior to being discharged to LTAC 6/15/22.

An interview was conducted with staff # 3 on the morning of 08/15/22. Staff #3 discussed process improvements related to multiple grievances on skin and tissue issues throughout the hospital. Staff # 3 stated that they had lost their WOCN (Wound Ostomy Certified Nurse) and were in the process of training a Registered Nurse (RN) for their WOCN or WCC (Wound Clinician Certified). An interview was conducted with staff #4 on the morning of 8/16/22 and stated that the RN sitting for the WCC was not quite ready to take the test; however, they are working with another WOCN to help this other nurse become trained. Staff #4 confirmed that the staff nurses were responsible for all skin care management.

Based on observation, document review and interview the facility failed to ensure a clean and sanitary environment to prevent the transmission of infectious diseases in 4 (Geriatric, Adult, Acute Adult, and Adolescent) of 4 units observed.


Findings Include:

Observation tours were conducted 8/15/2022

1. Geriatric Unit Storage room:

Storage room geriatrics contained medical equipment (clean and dirty), combined with donated clothing. Room was in extreme disarray, staff unable to discuss clean and dirty process of items.


2. Geriatric laundry room:

Washer/Dryer logs on the geriatric unit missing required daily audits from June and August 2022.

3. Patient rooms and bathrooms:

The bathroom in room 101 had a soiled patient shower (considered clean) as evidenced by a dirty cardiac electrode with hair and dirt, rust, dirt and debris resembling hair.

Shower stall of empty patient room with hair, dirt and debris.

Laminate floors in patient room were grossly soiled as evidenced by dark scratches, dingy, and scuffed with variations of discoloration. Space between baseboards and laminate filled with dust, debris, grime, and filth.

Patient room in obvious need of repair as evidenced by broken baseboards, holes in wall with multiple attempts to "putty" open areas, baseboards held together with medical silk tape. Patient room sink laminate broken and revealing sharp edges with the laminate lifting and trapping dirt and bacteria making it unable to disinfect or clean for safe patient use.

Patient geriatric room 103 shower with brown stains resembling rust from shower head. The shower chair in the patient shower room had a hole showing rust, foreign debris, and peeling of the assistive device.

Patient room 103 door-facing dislodged with crack in drywall, baseboard dislodged and broken, grossly packed with dirt and debris. There was broken laminate on sink with previous attempt at repair with sharp edges which could result in patient injury.

Patient room 108 with substance resembling mold trapped in blinds behind glass. There was filth behind the door in patient room and a sticky yellowish-brown substance stain on the floor. Broken laminate from inside of door which could result in patient injury. Corner of room revealed uncleanliness, dirt and debris trapped between unsealed baseboards and laminate flooring. Patient room 108 bathroom with missing caulk, caked with rust, dirt, and debris connecting to baseboard lifted from laminate trapping dirt and sticky substances. Above baseboards was broken drywall from previous attempts at repair and moisture damage. Behind patient room door, the threshold was covered in copious white and gray matter.

Adult patient room 226 with broken toilet seat which results in trapped bacteria and risk of patient injury and infection secondary to inability to disinfect. Curtains in patient room weresoiled with a dark brown substance and white sticky substance. EVS staff, supervisor, and manager unable to state when curtains are scheduled to be cleaned or disinfected, no log followed to display when curtains have been changed or laundered.

4. Hallways:

Flooring in hallway outside patient room, area between baseboard and laminate gapped and trapped gross debris, dirt, dust, sticky substances, and other particulate matter. Laminate floor tiles were lifted with unknown black substance, scratches, tears, scuffs, unsecured baseboard of glue base lifting away from wall and flooring.

Geriatric unit flooring in patient care area with peeled and/or dislodged attachment to wall resulting in trapped dirt, debris, sticky black/brown substance and overall uncleanliness leading to infection control risk for patients.

Geriatric unit flooring revealed partial dislodged screw risk for patient injury with noted uncleanliness behind the door in the corner as evidenced by dirt, debris, hair-like particles, and caked on gray black substance. A patient
room/bathroom with dislodged baseboards and broken dry-wall with previous attempts at repair which could result in patient injury, as well as risk for infection related to filth.

5. Day room(s):

Geriatric Day room flooring baseboard and laminate with caked in black sticky substance, dirt, debris, copious hairs and scuff marks on floors.

Geriatric Day room: Refrigerator log with missing temperature checks for the month of 8/2022. Broken baseboards and wall with sharp edges, thick dirt, debris, and overall uncleanliness. Geriatric Dayroom refrigerator, space between refrigerator and wall extremely filthy. Baseboards, flooring and side of refrigerator covered in a brown sticky substance, dirt, and debris. Inside of patient refrigerator had yellow sticky substance. Patient Refrigerator: inside of refrigerator grossly dirty with sticky substances and debris. The refrigerator vent and flooring caked with dirt, debris, and black sticky substance. Dayroom refrigerator food drawer was filled with unknown sticky clear and yellow substance.

Dayroom with splattered stains on wall and peeled wood on chairs unable to clean or appropriately disinfect resulting in increased risk of infection.

Adolescent dayroom refrigerator with baking soda and expired milk 2 months. Adolescent day room refrigerator dirty with rusted areas, expired cheese sticks by 5 days, refrigerator log with missing daily checks.

6. Elevator(s):

Elevator with broken florescent light covers revealing sharp edges and risk for injury.

7. Soiled Linen Room

Soiled linen room with blistered and peeling paint and drywall. Grossly filthy dustpan with layers of caked on dirt, debris, hairs, and sticky unknown substances.

8. Exam/Treatment Room

Patient evaluation room with soiled exam table paper which could lead to contamination and patient infection risk. Expired respiratory adjunct. and expired suction extension tubing. Bathroom of exam room with blue painter's tape covering the sprinkler, director unable to identify why item covered.

9. Clean utility room adolescent unit:

Clean utility room with bin filled with soiled gloves and soiled unclean flooring.

10. Acute care nurses' station:

Acute care nurses' station: soiled and filthy flooring with cords readily accessible in unsecured room which is a risk for self, patient, and staff injury.

11. Acute unit close observation or seclusion room area:

Door base in seclusion area with peeling laminate flooring resulting in filth of dirt and debris. Ceiling tiles stained and broken.