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Based on observation, interview and record review, the facility failed to provide wound care treatment intervention to 1 of 30 sampled patients, Patient #15

Findings:

Observation on 3/17/2014 at 2:20 PM revealed the facility's wound nurse with the assistance of another Registered Nurse approached Patient #15 in ICU 200 F and explained that she is going to do his wound dressing. Observation of the pressure ulcer wound revealed an unstageable wound with black tissues (80% eschar) that were not present 2 days ago as evidenced by the wound photo taken on 3/15/2014 at 1713. Wound bed is moist with irregular edges. The wound nurse measured the wound and obtained 9 cm x 10 cm x 0.5 cm. Wound nurse concurred that the wound now has 80% eschar formation. Wound nurse cleansed the area with a gauze soaked with normal saline, patted it dry. She covered the wound with a gauze moistened normal saline and an ABD pad, then covered with occlusive dressing. Wound nurse stated that the treatment was for wet to dry normal saline until seen by the wound Doctor.

Interview with the wound nurse on 3/17/2014 at 2:25 PM stated that Patient # 15 came in from a skilled nursing facility with an unstageable wound in the coccyx area. She stated that the Physician ' s order for wound care include wet to dry normal saline until seen by a wound specialist for wound debridement.

Record review of Patient # 15 revealed an admission date of 3/15/2014. The facility took a photo of the wound upon admission on 3/15/2014 at 17:13. Emergency room notes revealed a visualized open draining wound.

Review of the physicians order history provided by the Director of Critical Care Services dated from admission 3/15/2014 through 3/17/2014 did not reveal any wound dressing treatment orders to the coccyx area.

Interview with the RN Director of Critical Services on 3/17/2014 at 3:10 PM stated that when a new patient is admitted to the intensive care unit, an initial assessment is made by a Registered Nurse (RN). She stated that it is the facility ' s protocol to take wound pictures upon admission and upon discharge. She said that the admission nurse will request a wound consult physician and a consult with the hospital's wound nurse and if the wound consulting physician and wound nurse are not available on the weekends, the admission nurse will call the physician for wound orders. Director of Critical Care stated when asked if the admission nurse was notified and obtained an order for wound care treatment upon admission for Patient # 15, she replied; " I don ' t think he got an order " . The Director of Critical Care Services concurred on 3/17/2014 at 3:27 PM that there was a breakdown of the units' protocol and unable to provide a documentation of a treatment order. When asked if she could provide documentation that the unstageable wound dressing was changed on 3/16/2014, she replied she has none and was not able to provide any documentation that the dressing was changed on 3/16/2014. She stated that the admission nurse was a Premium Pool nurse and works whenever days he is needed in no specific unit.

Interview with the wound nurse on 3/17/2014 at 3:05 PM stated that she has a wound protocol and notifies the physician for orders. The wound nurse provided a physician's order entered on 3/17/2014 at 15:02, today after Surveyor intervention that revealed a dressing change order that reads: Cleanse coccyx wound with sterile saline and apply saline moistened dressing wet to dry BID.

Review of Patient # 15 plan of care dated 3/15/2014 revealed under Integumentary: Goal: Skin intact without breakdown. Wounds healing. Intervention includes: Focused care is Integumentary, see risk assessment documentation for patient specific interventions.

Based on observation, interview and facility policy and procedure review, the facility failed to implement appropriate sanitary techniques and failure to adhere to infection control practices in 3 of 30 sampled patients. Patient # 12, # 15 and # 16.

Findings:

During medication observation pass on 3/18/2014 at 9:00 AM revealed the primary nurse for Patient # 12 was preparing to administer the morning medications for this patient. The primary nurse first administered all oral medications. Then the primary nurse donned a pair of gloves and administered the nasal spray. Nurse removed her gloves and proceeded to the computer that was on top of a rolling cart near the foot of the patient's bed. Then nurse used the hand sanitizer near the door, pushed her rolling cart and exited the patien'ts room. Primary nurse failed to wash her hands after removing her gloves and before exiting the patient's room. Interview with the primary nurse on 3/18/2014 at 9:30 AM stated and concurred that she did not wash her hands after removing the gloves and replied; " I used the hand sanitizer:"

Observation on 3/17/2014 at 2:55 PM revealed the Laboratory phlebotomist approached the patient in room G - Patient # 16 and identified patient by asking her name and date of birth. She explained that she is going to draw blood for cardiac enzymes. She donned a pair of gloves, applied a tourniquet on left wrist. She prepped the dorsum of right hand with alcohol prep. She opened a butterfly needle and proceeded to do a needle stick. Obtained a 4 ml of blood using a green top tube. She pulled the butterfly needle, briefly applied pressure on the puncture site. She labeled the tube, removed her gloves and thanked the patient. She sanitized her hands with an antiseptic hand gel, carried her lab tray and exited the unit. She did not wash her hands before and after removing her gloves per facility policy.

Observation on 3/17/2014 at 2:20 PM revealed the wound nurse with the assistance of another Registered Nurse approached Patient # 15 in ICU 200 F and explained that she is going to do his wound dressing. Nurse donned personal protective equipment (PPE), such as mask, gloves and gown. Patient was turned to his right side to expose the coccyx wound. Nurse removed a duoderm dressing and tossed in trash can. Observation of the pressure ulcer wound revealed an unstageable wound with black tissues (80% eschar). e. The wound nurse measured the wound and obtained 9 cm x 10 cm x 0.5 cm. Wound nurse cleansed the area with a gauze soaked with normal saline, patted it dry. She covered the wound with a gauze moistened normal saline and an ABD pad, then covered with occlusive dressing. Wound Nurse discarded all the used dressings in the trash can, removed her gloves. Nurse used the hand gel sanitizer from the wall and exited the room. Wound Nurse did not wash her hands before and after removing the gloves and after patient care. Both nurses did not wash their hands before direct contact with the patient as indicated in the facility ' s hand washing policy.

Interview with the facility's Infection Control Nurse on 3/19/2014 at 3:30 PM revealed that she provides the infection control educational training during orientation and annually and in between as needed. When asked what is the facility's policy regarding hand washing, she replied; " Even if you just enter a patients room and say Good morning, you have to wash your hands before leaving the room, staff also must wash their hands before and after removing gloves. "

Review of Ocala Regional Medical Center Hand Hygiene Policy with an effective date of 11/11 and a review date of 04/2013 revealed on page 1 of 3 under Policy reads:
A. Hand washing - wash with soap and water for a minimum of 20 seconds when:
Before and after having direct contact with patients
After removing gloves
Upon every entry and exit from a patient room or patient area.