HospitalInspections.org

Based on observation and record review the facility failed to protect the patient from exposure to disease causing pathogens (microorganisms that cause disease) for 1 (P (Patient) P6) of 11(P1-P11) patients. This deficient practice could likely cause infection, sepsis (a very serious life-threatening medical emergency), or death of all patients in the facility.

The findings are:

A. Record review of the facility's policy "Hand Hygiene" "Effective Date: 11/08/2022" revealed:

1. "Hands will be decontaminated by using an alcohol-based hand cleanser ...or soap and water in the following clinical situation: After contact with body fluids or excretions (waste materials like urine or feces) ...wound dressings."

B. During an observation on 02/22/2024, at 1:00 pm of a dressing change performed on P6 by Staff (S)11, Registered Nurse (RN). S11 applied hand sanitizer before entering the room and putting on gloves. S11 placed the open clean dressing packages directly on the patient's sheet without a barrier (an underpad or disposable sheet used to protect items that are placed on top, like dressings, from what may be on the sheets or bed, like stool).
S11 then removed a dressing from a 2 centimeter (cm) (a measure of length) by 2 cm unstageable pressure wound (a type of pressure wound that has a full-thickness skin and muscle loss with dead tissue covering the wound bed preventing the assessment of the true depth of the wound) on the left knee, applied (a brand name wound gel made from honey) with a finger, and placed the new dressing over the wound. S11 then removed the dressing from a 1.5 cm by 1.5 cm P6's right heel, applied (a brand name wound gel made from honey) with the same finger, and placed a new dressing over the wound. S11 did not change gloves or perform hand hygiene between the dressing changes on the two sites potentially cross-contaminating the right heel wound with pathogens from the left knee wound by using the same gloved finger to apply (a brand name wound gel made from honey). It was later observed that there was stool (feces) leaked from P6 colostomy (an opening in the belly that connects the colon to the skin to empty stool to the outside of the body into a bag) on the sheet where the clean dressing packages were placed potentially contaminating the dressings with stool. Contamination of wounds with pathogens and/or stool could cause infection, sepsis, or death as a result of sepsis.