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Based on observation, interview, record review, and policy review, the provider failed to ensure proper infection control practices were maintained for three of three observed patients (2, 3, and 4) during wound care dressing changes by one of one wound care registered nurse (RN)(D). Findings include:

1. Observation and interview on 3/13/24 at 8:30 a.m. of patient 4's multiple dressing changes with RN D and an unidentified nursing student in the patient's room revealed:
*The patient had a recent surgery on her left hip.
*RN D worked as the provider's wound care nurse since August of 2023.
*RN D removed the dressing supplies from a supply closet and from a treatment cart located outside of the patient's room.
-She entered the patient's room and placed those unopened supplies directly onto the patient's bedding.
*She sanitized her hands, applied a clean pair of gloves, removed the patient's socks, palpated her heels, and asked about her pain.
-Using those same gloved hands, she:
-Removed a gauze dressing from the patient's left lateral knee area and palpated around and squeezed the edges of a small skin incision that contained approximately 4 staples.
-Removed two large dressings from the patient's left lateral hip and palpated around and directly on top of both suture sites that contained multiple staples with surrounding dark purple skin.
*She then removed those gloves, sanitized her hands, applied a clean pair of gloves, and then lifted the patient's abdominal and axillary skin folds and inspected underneath her breasts and armpits.
-Using those same gloved hands, she removed a dressing from the patient's right side of her neck, identified that the site was a previous central line access area, and palpated directly on the small scabbed area that remained.
*She removed those gloves, sanitized her hands, and applied a clean pair of gloves.
-With the assistance of the unidentified nursing student, she rolled the patient onto her right side and inspected her back and lifted her buttocks to view her perineal area.
-Using those same gloved hands, she picked up a cellular phone and took pictures of all the above mentioned wounds by placing the same paper measuring tape directly onto the patient's skin above each surgical area.
*She removed those gloves, sanitized her hands, applied a clean pair of gloves, then she:
-Removed the unopened packages of dressings from the patient's bedding and opened the dressing packages.
-Set the opened packages directly on the patient's over-bed table, pulled a pen marker out of her uniform pocket and dated the new dressings.
-Returned the opened dressings onto the patient's bedding.
-Using those same gloved hands, she applied the clean dressings to the two left hip surgical sites.
-The sites above the left knee and the right neck remained uncovered.
*None of the surgical sites were cleansed after the removal of the soiled dressings, after being touched by her gloved hands, or before the application of the clean dressings.
*She disposed of the used dressing supplies, removed her gloves, and sanitized her hands.
-Without wearing gloves, she picked up the unsanitized cell phone and marker pen, opened the patient's door, and returned those items to the hallway treatment cart's tabletop surface before those items were sanitized.

Review of resident 4's electronic medical chart revealed:
*She was admitted on 3/6/24 with the following diagnoses: intertrochanteric (hip) fracture with open reduction and internal fixation (ORIF); acute exacerbation of chronic obstructive pulmonary disease (COPD); type 2 diabetes mellitus with hyperglycemia; acute kidney injury (AKI) due to sepsis; and mixed anxiety with depressive disorder.
*A 3/6/24 physician's order for her above-the-knee and left hip dressing changes included cleansing the sites with normal saline before the application of clean Telfa (non-adherent) dressings.
-That process was not observed during the dressing changes.

2. Observation and interview on 3/13/24 at 8:55 a.m. of patient 3's dressing change with RN D revealed:
*RN D stated she had become certified in wound care in July of 2023.
*She carried a cell phone and paper measuring tape into patient 3's room and placed those items directly onto a treatment cart located in the patient's room.
-The patient's clothing was piled on top of the treatment cart's surface.
*RN D sanitized her hands and applied a clean pair of gloves, she then:
-Removed the dressing supplies from the treatment cart and placed the unopened dressing supplies on a washcloth that was placed on the patient's bedding.
-Removed a large absorbent dressing from the center of the patient's abdomen which revealed a large surgical incision from the middle of his abdomen extending down to the lower abdomen.
-The surgical incision contained multiple staples and had a light pink periphery which extended out approximately three centimeters around the incision site.
-There was an ileostomy (part of the small bowel that was brought through the abdominal wall via a surgically-created opening called a stoma) collection bag located on the right mid-abdomen next to the surgical incision.
-There was an approximate one-centimeter circular, deep, drainage-type skin opening just below the lower abdominal incision that had drained a moderate amount of yellow-colored drainage onto the removed dressing.
*RN D removed her gloves and without sanitizing her hands she then:
-Removed one clean glove from a glove container, then returned that glove into that same container of clean gloves.
-Sanitized her hands and applied a pair of gloves from that same container.
-She placed the measuring tape on the patient's skin next to the surgical site and used her cellular phone to take a picture of the site.
-She placed the phone back on the treatment cart next to the patient's clothing.
*Using those same gloved hands, she irrigated the surgical sites with a needleless syringe of sterile saline and dabbed the moistened sites with a sterile gauze pad.
*After cleansing those surgical sites, and using those same gloved hands, she then:
-Palpated the entire periphery of the incision and then pushed down lightly on the stapled incision along the entire length of the abdomen.
-Picked off a small piece of loose skin from one of the staples.
*She removed her gloves, sanitized her hands, applied a clean pair of gloves, and then she:
-Removed scissors and more dressing supplies from the treatment cart, opened packages of dressings, cut a piece of absorbent foam dressing, then placed the scissors on top of the treatment cart next to the cellular phone and the patient's clothing.
-Removed a marker from her uniform pocket and dated the dressings.
-Returned the unsanitized scissors into a drawer on the treatment cart.
*Using those same gloved hands, she:
-Applied the dressings onto the patient's surgical site.
-She disposed of the soiled dressing supplies, removed her gloves, and sanitized her hands.
*Without wearing gloves, she then picked up the unsanitized cell phone and marker pen, opened the patient's door, and returned those items to the hallway treatment cart's tabletop surface.
-She opened the treatment cart's drawer and removed a sanitizing cloth, then applied a pair of clean gloves.
-She sanitized the cell phone and the marker, then placed them back onto the same unsanitized surface of the cart.
-She wiped the surrounding cart surfaces with the sanitizing cloth.

Review of resident 3's electronic medical chart revealed:
*He was admitted on 2/24/24 with the following diagnoses: small bowel obstruction; Crohn's disease of both small and large intestine with intestinal obstruction; moderate protein-calorie malnutrition; hypoalbuminemia due to protein-calorie malnutrition; essential hypertension; and bipolar disorder.
*A 3/5/24 physician's order for the patient's surgical site to have been cleansed with normal saline and covered with absorbent dressings when the dressings were no longer intact or when damp, moist, or saturated.
-That process was observed during the dressing change.

3. Observation on 3/13/24 at 9:45 a.m. of patient 2's dressing change with RN D revealed:
*RN D removed the dressing supplies and an unopened bottle of normal saline from the treatment cart located in the hallway and set them on top of a closed laptop computer on the cart's surface.
-She then carried those supplies, a cellular phone, and a measuring tape, into the patient's room and placed them, unopened, on a disposable barrier pad.
*The patient had a large abscessed wound located on her abdomen and a recent right sided above-the-knee amputation surgical site.
*She sanitized her hands, and applied a clean pair of gloves.
-She inspected and directly touched dried scabs that were located on the patient's above-the-knee amputation surgical site.
-Using those same gloved hands she:
-Removed several large absorbent dressings from the patient's mid-abdomen exposing layered gauze in a wound bed.
-Removed the dried gauze that was layered into an abscessed cavity exposing a large, meaty-appearing, full-thickness abdominal abscess with the approximate circumference of a basketball.
-Covered the patient's abdominal abscess using the hospital gown the patient was wearing.
*She then removed her gloves, sanitized her hands, and applied a clean pair of gloves.
-Using one of her gloved hands, she pulled the hospital gown up and off the abdominal abscess site and tucked the gown along the patient's breast line.
*Using those same gloved hands, she:
-Opened a package of gauze and opened the normal saline bottle.
-Poured the normal saline onto the gauze pad and cleansed the abscessed site using a wiping motion in a right-to-left, top-to-bottom fashion.
-Reached over to the room's garbage can and pulled it closer to the bed to dispose the used gauze dressing.
-Opened another package of gauze and sporadically patted the wound bed with that gauze until the abscess was mostly dry.
*She removed her gloves, sanitized her hands, applied a clean pair of gloves, she then:
-Picked up the cellular phone and measuring tape, applied the measuring tape directly onto the patient's skin next to the abscess, and took pictures of the abdominal abscess.
-Placed the cellular phone back on the disposable barrier pad and discarded the measuring tape.
-Opened a package of rolled gauze, held the gauze over the garbage can, and poured the sterile normal saline onto the gauze.
*Using those same gloved hands, she then:
-Unrolled and layered that wet gauze into the abscess's wound bed, covering the majority of the abscessed site.
-Removed several large absorbent pads from the packaging.
-Removed a marker pen from her uniform pocket, and dated the absorbent pads.
*She removed her gloves, and without sanitizing her hands, she applied a clean pair of gloves and applied those large dressings over the layered, wet gauze.
-She left an approximate two-inch section of abscessed wound exposed on the lower right side of the patient's abdomen.
*She removed her gloves and sanitized her hands.
-With her bare hands she removed a roll of tape from the resident's closet.
-She placed the tape on the resident's blanket laying on the bed.
*Without sanitizing her hands, she applied a clean pair of gloves and taped the edges of the dressings to the patient's skin.
*She placed tape directly onto the small section of the exposed abscess on the lower right side of the patient's abdomen.
*She removed her gloves and sanitized her hands.
-With her bare hands, she opened the patient's closet door and placed the tape inside.
*Without sanitizing her hands, she:
-Applied a clean pair of gloves, removed the barrier pad, and placed it into the garbage.
-Removed those gloves, opened the patient's door, and carried her unsanitized cellular phone and pen back to the treatment cart in the hallway.
-Applied a clean pair of gloves, opened the treatment cart drawer, and removed a sanitizing cloth from the treatment cart.
-Sanitized the cellular phone and the pen, then placed them onto the back side of a clipboard that was lying face down on the treatment cart.

Review of resident 2's electronic medical record revealed:
*She was admitted on 2/15/24 with the following diagnoses: peripheral artery disease (PAD) with gangrene of the right lower extremity, status-post right above-the-knee amputation (AKA), obesity, deep vein thrombosis, acute respiratory failure with hypoxia, hypertension, encephalopathy, sleep apnea, seizure disorder, bipolar disorder, and covid related pneumonia.
*A current 3/5/24 physician's order for "7 o'clock of abdominal wound apply Ag rope drsg [dressing] and cover with duoderm. Dressing change weekly and as needed."
-That dressing application was not observed during the dressing change.
*A 3/8/24 physician's order to "Cleanse the abdominal wound with normal saline and apply moist-to-moist kerlix to wound bed, cover with ABD [abdominal dressing], and secure with tape."
-That order had not indicated if the dressing change was to have been a clean procedure or a sterile procedure.

Interview on 3/13/24 at 12:45 p.m. with RN D regarding the above wound care observations revealed:
*Regarding patient 4's observation:
-She confirmed dressing removal was considered a dirty procedure.
-She stated she had not felt that touching scabbed or approximated skin areas using the same gloved hands as the dressing removal was considered a potential for contamination, and was not concerned about using the same gloves for the dressing removal.
-She could not remember if she had touched the hip incisions with those same gloved hands.
*Regarding patient 3's observation:
-She stated the only wound she had been concerned with was the drain hole opening below the incision, and she had only touched around that site.
-She could not remember touching the staples following the cleansing of the stapled incision.
-She stated, "The top of the wound, for me, is already healed and the skin is intact. I was pulling off dead skin. I was not worried about touching it (with the gloves she had used during dressing removal)."
-She confirmed patient 3's abdominal incision still had staples remaining in his skin.
*Regarding patient 2's observation:
-She could not remember pulling the garbage can closer to the bed during her cleansing of the patient's abscess.
-She stated if she had done that, she would normally have removed her gloves and sanitized her hands.
-She had cleansed the marker after each use and before she placed it into her uniform pocket.
-She agreed that she had placed her bare hands in her uniform pocket multiple times a day and that could have been considered an unclean environment.

A dressing change policy had been requested on 3/13/24 following the above observations and interview of RN D. Director of nursing services (DNS)(B) stated there was not a specific dressing change policy. She stated those subjects were covered in the dressing change competency audits of wound care staff.

Interview on 3/14/23 at 12:46 a.m. with the director of quality management (C) and DNS (B) regarding the above dressing change observations revealed:
*The expectation was for hand hygiene and application of clean gloves following the removal of used dressings.
*They expected a barrier pad to be used for a sterile dressing change, but it was not expected for a clean dressing change.
*Confirmed palpating directly over or around multiple surgical sites with the same gloves used in a dressing change was not a clean procedure and not their expectation.
*They confirmed there were multiple missed opportunities for RN D to have performed proper hand hygiene and glove use.
*RN D had been audited for wound care competency and had passed.

Review of RN D's 9/6/23 competency audits for: Sterile dressing; Non-sterile dressing; and Applying gauze and elastic bandages, revealed she had met all the audit criteria expectations. The non-sterile dressing audit had not included hand hygiene and changing gloves following cleansing of the wound and before the application of clean dressings.

Review of the provider's April 2023 Hand Hygiene policy revealed:
*Hand hygiene was to be performed:
-"2. Before and after every patient contact[.]"
-"3. Between patient care activities within the same episode of care[.]"
-"4. When moving from high contamination patient care activities/if moving from a contaminated body site to a less contaminated body site (peri-care to trach care)[.]"
-"9. Between glove changes and after removing gloves[.] After any contact with body fluids, dressings, patient linen[.]"
-"11. Before going into a patient room and before leaving a patient room[.]"

Review of the provider's April 2023 Standard Precautions policy revealed:
-"4. Gloves will be changed after every patient contact, when moving from dirty to clean task..."
-"10. Hand hygiene must be performed prior to putting on gloves[,] after removing gloves. Gloves do not replace the need for hand hygiene."
-"Patient Care Equipment: 1. Patient care equipment known to be contaminated with infective material should be cleaned with a disinfectant-germicidal solution at the point of use..."