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Based on record review, staff interview, and policy review, the facility failed to ensure the patient received care in a safe setting for one of eleven medical records reviewed (Patient #2). The facility census was 98.

Findings include:

Review of the policy and procedure for Patient Rights and Responsibilities effective 07/27/18, revealed patients will receive care in a safe environment.

Review of Patient #2's record revealed the patient was admitted to the facility on 09/06/19 with diagnoses of sinusitis and cystitis. Review of documentation revealed Staff O performed an admission assessment on the patient on admission to the rehabilitation unit on 09/06/19. Patient #2 informed his/her family and facility staff he/she was very uncomfortable with the assessment performed by Staff O. Patient #2 was informed Staff O would no longer be assigned to provide his/her care. On 09/15/19 Staff O answered Patient #2's call light. Patient #2 became upset and notified family members of this incident. Review of facility documentation revealed Staff O had not been informed the patient was uncomfortable with his/her care and just thought he/she was placed on a different assignment.

Interview with Staff B on 09/26/19 at 2:30 PM confirmed the above findings. Staff B confirmed Staff O was not made aware of the patient's wishes.

Based on observation, interview and record review, the facility failed to develop a system for controlling infections for one of one patients observed receiving a dressing change (Patient #11). The sample size was eleven patients. The patient census was 98.

Findings include:

Review of the hospital policy title, Hand Hygiene Policy effective 02/19/19, revealed hand hygiene should always be performed before putting gloves on and after taking gloves off.

Review of the medical record revealed Patient #11 was admitted to the hospital on 09/20/19 with a diagnosis of cellulitis to the right great toe. The physician orders dated 09/21/19 were for a dressing change to the right great toe with betadine gauze two times a day.

Observation was made on 09/27/19 at 10:50 AM of Staff G providing a dressing change to Patient #11's right great toe. Staff G washed his/her hands with soap and water and applied clean gloves. Staff G reached into his/her left pocket for a small pair of scissors and cleaned the scissors with an alcohol swab. Staff G then cut the dressing off the patient's right foot and then disposed of the dirty dressing in the trashcan. Staff G then removed the now dirty gloves, but did not wash his/her hands with soap and water or use hand gel. He/she and then put on a pair of clean gloves. Staff G opened up a container that had four by four dressings in it and sprayed the four by fours with derma wound cleanser. Staff G used two of the four by fours to clean the wound to the patient's right great toe. Staff G did not remove the now dirty gloves, but proceeded to grab the betadine bottle and then soaked more four by fours with betadine. Staff G wrapped the right great toe with the four by fours that were soaked in betadine and then removed his/her dirty gloves and did not wash his/her hands. Staff G then put on a pair of clean gloves, applied a clean dressing to the right great toe and wrapped the right foot with a sterile gauze. Staff G cleansed the scissors with an alcohol swab and put the scissors back in his/her pocket. He/she reached in his/her pocket for a pen with the gloves on and initialed and dated the dressing before removing his/her dirty gloves and washing his/her hands with soap and water.

This finding was verified with Staff G and Staff C on 09/27/19 at 11:20 AM on 09/27/19.

This deficiency substantiates Substantial Allegation OH00107347.