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Based on observation, interview and policy review the facility failed to ensure infection control practices were followed for 2 of 23 sampled patients (P3 and P23) observed during wound care resulting in the potential for increased risk of infections.

Findings include:

1. On 11/11/19 at 12:30 PM during a wound care observation of P3, prior to entering P3's room to complete a wound vacuum dressing change (a closed wound care system) the Wound Care Registered Nurse (WCRN) was asked why P3 was on contact isolation, she stated " ...I'm not sure ..." The WCRN made no attempt prior to completing the dressing change to verify why P3 was on contact precautions. After donning the required personal protective equipment (PPE) of gown and gloves, the WCRN failed to tie her gown up and left it "dangling open" so when she leaned over, her uniform was left exposed to potential infectious material.

During the same wound vacuum dressing change on P3, the WCRN removed a pair of scissors from her uniform pockets, from underneath her untied PPE gown with gloves on, and used the scissors to cut the foam used for the dressing. The scissors were not observed to be cleaned before the WCRN used them or after use. When the WCRN was finished, she removed her gown and gloves, but was not observed to wash her hands or use hand sanitizer before leaving the room.

Record review for P3 revealed she was admitted on 10/30/19 and placed on contact isolation precautions due to methicillin resistant staphylococcus aureus (MRSA) in her wound.

On 11/12/19 at 1:50 PM during an interview, the Assistant Director of Nursing (ADON) and the Infection Control Preventionist (ICP) stated the expectation would be for scissors to be cleaned, before and after a dressing change, and that hand hygiene was completed before and after a procedure, and when removing gloves. The ICP also stated, when possible, non-critical equipment should be dedicated to patients who require isolation precautions.

2. On 11/12/19 at 12:10 PM, an observation of a WCRN performing wound care on P 23 revealed P 23 had wounds located on both lower legs that were wrapped with 4-inch-wide gauze. After the WCRN positioned P 23, she removed a pair of scissors from her left shirt pocket and without cleaning, she cut first the gauze on the left leg then the gauze on the right leg. The WCRN then placed the scissors on top to the biohazard container located on the floor next to P 23's bed. When the wound care was completed, she removed a bleach wipe from the wound care cart, cleaned the scissors and put time back in her pocket.

After removing the gauze wrap from the patient's right lower leg the WCRN attempted to remove two dressing on the patient right calf. The dressings were adhered to the wounds, so the WCRN took a 2 inch by 2-inch gauze and soaked it with Dakin's solution and used the wet gauze to remove the dressing from the lower right calf. The WCRN used the same wet gauze to remove the dressing from the second wound. The second wound was located approximately 3 to 4 inches above the lower wound.

On 11/12/19 at 10:20 PM following the observation, the WCRN revealed she cleaned the scissors after performing the last wound care prior to putting the scissors in her pocket. When asked if using the same soaked gauze to remove the two dressing on P23's right calf was acceptable infection control practice, the WCRN stated that she was nervous, and she should have used a separate clean gauze for each wound.

On 11/12/19 at 1:15 PM, the ICP revealed the facility did not have a policy and procedure that addressed using the same gauze for more than one wound, but considered the practice to be unacceptable.

Review of the facility policy and procedure "Hand Hygiene/Hand Washing" dated 11/27/17, it stated under bullet point 2 "Wash hands", c " ...before putting on gloves, when changing into a fresh pair of gloves and immediately after removing gloves ..." and f " ...before and after patient/resident contact ..."

Review of the facility policy and procedure "Infection Prevention and Control - Isolation/Precautions including Standard/Universal Precautions", dated 11/27/17, it stated under bullet point 2 "Personal Protective Equipment" d " ...wear a gown (clean, non-sterile gown) to protect skin and prevent soiling of clothing during patient/resident care activities that are likely to generate splashes ..." and e " ...verify that reusable patient/resident care equipment is cleaned and reprocessed appropriately ..."

Based on interview, record review, and review of facility documentation, it was determined the facility failed to notify the Organ Procurement Organization (OPO) for 1 of 2 Patients (P) (P21) death records reviewed.

Finding include:

Review of P21's medical record revealed the facility failed to contact the OPO after the death of the patient. P21 was admitted to the facility on 05/10/19 with a diagnoses of acute kidney failure and viral hepatitis C. The medical record revealed P21 expired on 05/15/19. Nurse Progress notes revealed Registered Nurse (RN) 1 notified the patient's family and the mortuary. However, there was no evidence in the medical record the OPO was notified of P21's death on 05/15/19. RN1 was not available for interview.

On 11/12/19 at 11:00 AM, the Assistant Director of Nursing (ADON) reviewed P21's medical record and confirmed there was no evidence of notification to the OPO regarding the death of P21.

On 11/12/19 at 1:15 PM, the Chief Executive Officer (CEO) stated the ADON contacted the OPO on 11/12/19 at 12:34 PM and the OPO confirmed there was no notification of the death of P21 made to the OPO. The CEO acknowledged the notification should have been made but could not provide an explanation for the failure.

Review of the facility's nursing policy titled, "Organ, Tissue and Eye Donation", dated revised 11/01/14, stated, "When death is imminent ...or upon death of a patient, the attending physician, the CNO [Chief Nursing Officer] or designee shall contact the organ procurement organization to report all deaths." In addition, the policy further stated, "The hospital shall work collaboratively with the organ procurement organization to assist with any further coordination as outlined in the Organ and Tissue Recovery Agreement."

Review of the hospital's Organ and Tissue Recovery Agreement with the OPO, dated 02/01/12, stated the hospital was responsible to, "Refer all deaths to the OPO in a timely manner according to standard clinical triggers. Referrals will be made within one hour of cardiac standstill or when brain death is imminent, defined as a Glasgow Coma Scale (GCS) of 5 or less, or when the family is considering withdrawal of care ...The OPO staff will determine the patient's eligibility for donation.