HospitalInspections.org

Based on review of facility documents and interview with staff, the facility failed to verify required licensure of one of two Contracted Registered Nurse's (RN E) on the facility current roster.

Findings include:

Review of two (2) agency "contracted" nurses revealed one Nurse RN - E hired 8/5/22 had no verification of any license available in the facility and no record of any training or background check.

Interview with Human Resource staff member on 9/21/22 at 11;15am revealed that no record of licensure was available for RN-E from the agency and background checks had not completed in the past year.

Based on observations, record review and staff interview, the facility failed to provide a sanitary/pest free environment.

Findings include:

A. Initial tour of the facility on 9/20/22 at 11:00am, revealed six live crickets of sizes ranging form 1/4 inch to over one inch in length in the conference room adjacent to the dining room. Four crickets that were no longer alive were noted on the floor under the table and around the edges of the room. Cobwebs were also noted on the lower edges of the small table against the East wall, the northeast corner wall and the interior window ledges on the North wall. At 4:10pm a live spider measuring 3/4 inch was found on the floor of the conference room.

On 9/20/22 during initial tour of the facility A cricket type but was seen crawling on the floor of the Emergency room bay area under construction. In patient room 4 a large 1+ inch thick spider was found on the floor. In the Hallway by interior courtyard door was a cricket 3/4 inch in length. The hospital bed (un occupied) in the first licensed room on the North end of the hall had dirt like substance under to foot of the bed. Cobwebs were noted lining the interior of the courtyard door, the ceiling and the wall corners adjacent to the exit door. The Exterior Exit door across the hall exiting to the West also has cobwebs on the ceiling and throughout the interior door/window ledges. The outside courtyard door jam was covered in cobwebs, wasp nest and

On 9/20/22 in the staff breakroom where food was available and open on the table, a small 1/4 inch spider was noted crawling on the wall. Cobwebs were noted on the window casing in the staff breakroom with three (3) small dead bugs found on the carpet by the window.

On 9/21/22 in the entrance vestibule at 9:20am a live thin spindly spider was observed climbing the wall.
In the conference room a live spindly spider was found on the floor and a dead larger 1/2 inch thicker body spider was found.

on 9/21/22 at 12/55pm a live wasp was observed in the patient care hallway adjacent to room 5 and 6. A fly swatter at the nursing station was obtained to get rid of the wasp. A small thin spindly spider was found in the corridor by Room 11.

On 9/22/22 at 9:35am, a large cricket and an small spider were noted on the floor in the conference.

B. Interviews during the survey with seven (7) nursing staff revealed concerns with pests in the facility. Spiders and bugs, crickets etc
Review of Housekeeping Staff schedule noted only ONE (1) individual was scheduled to work 40 hours per week to do the cleaning of the entire hospital, Emergency Rooms, Rural Health Clinic.

C. Review of the facility contract for Pest control revealed a representative was only onsight in the facility once a month over the last 6 (six) months and was present in the building for an average of 39 minutes only. The report did not list any further information about products used, interventions tried or any concerns identified.
PC (pest control) standard reports listed no information other than the time in the building for each monthly visit.

3/9/22 - recorded 34 minutes onsite.
4/7/22 - recorded 61 minutes onsite.
5/6/22 - recorded 31 minutes onsite.
6/29/22 - recorded 32 minutes onsite.
7/2/22 - recorded 35 minutes onsite.
8/25/22 - recorded 40 minutes onsite. ( 52 days since previous visit 7/2/22).

Based on patient care observations, patient & staff interview's, review of policy & procedures and record reviews, the facility failed to meet the Condition of Participation for Provision of Services. The Provisions of Services related to this failure included the following of policy & procedures in medication administration, ensuring that the supplies were needed to carry out the cares of the patients including wound dressings and point of care glucose testing's, and nutritional assessment and reassessment as changes of conditions dictate with provider updates. These failures had the potential for causing harm to all patient being treated in the Critical Access Hospital. The facility census was 5.

Findings are:

Cross Reference to the following tags:
A. (C1006)- The facility failed to follow their policy and procedure for medication administration related to: a) not asking the patients name prior to administering medication of a patient without a hospital name bracelet; b) not having second nurse verification of insulin dose; c) providing insulin and topical cream to a patient that did not have a label present on the medication to identify who the medication was to be dispensed; and d) medication practices of managing a double lumen PICC line.

B. (C1016)- The facility failed to follow their policy and procedure for dressing changes, colostomy care and point of care blood sugar testing related to the frequent lack of all supplies necessary to provide the service to the patient per the procedure.

C. (C1020)- The facility failed to follow their policy and procedure for assessing and reassessing the ongoing nutritional needs of all patients in the care of the Critical Access Hospital.

D. (C1024)- The facility failed to follow their policy and procedure for ensuring all staff were properly trained in the use of the point of care blood sugar testing machine equipment.

E. Interview on 9/26/22 at 11:20 AM with the Clinical Service Manager and the Director of Nurses verified that the facility did not follow their policy and procedures as described above related to medication administration, dressing/colostomy and point of care blood sugar testing supplies, assessing and ressessment of ongoing nutritional needs of the patients and the proper training of staff on the use of the point of care blood sugar testing machine.

Based on medication administration pass observations, staff interviews and review of policies and procedures the facility failed to ensure that patient care policies were being followed or established on 2 (Patient 1 and Patient 4) of 9 patients. The failed practices during the observations included: a) not asking the patients name prior to administering medication of a patient without a hospital name bracelet; b) not having a second nurse verify the drawn up insulin dose; c) providing insulin and topical cream to a patient that did not have a label present on the medication to identify who the medication was to be dispensed; and d) medication practices of managing a double lumen PICC line. This failed practice has the potential to effect all patients the facility serves. Facility census was 5.

Findings are:

A. On 9/21/2022 at 11:50 AM a medication pass observation revealed RN-B preparing medications for Patient 4 in the hallway outside of the patients room. While preparing the medications for administrations, each medication to be administered must have a bar code on the container that it is stored in. RN B then located the MAR (medication administration record) in the electronic medical record for Patient 4. The medications were then to be scanned to ensure that the medication removed from medication workstation for Patient 4 and the MAR matched. RN B carried 2 additional medications (An insulin Pen and an arthritic topical gel Diclofenac Sodium Gel) that lacked a bar code or Patient 4's name into the room. Prior to RN B entering Patient 4's room, RN B scanned a patient sticker on the medication workstation, instead of an armband for Patient 4 to verify the correct patient's. Upon entering the room RN-B administered the medication to Patient 4. RN B DID NOT have the patient identify self by asking their name or date of birth after entering Patient 4's room or before medications were given.

B. On 9/21/2022 at 11:50 AM an interview with RN-B during medication pass revealed that (gender) did not like to take the computer workstation into the patient rooms because of the lip on the flooring into patient room. This caused medications or other items to spill or fall off workstation when going over the lip on the flooring. RN-B then revealed that since (gender) did not take the workstation into the patient room that (gender) scanned a patient sticker instead of the patient's armband to bring up the MAR. F. RN-B confirmed that the Insulin Pen and the arthritic topical gel Diclofenac Sodium Gel were not labeled with patient information and administration order. When asked who labeled medication RN-B stated that pharmacy labels the medication.

C. On 9/21/2022 at 12:30 PM an interview with the D.O.N (Director of Nursing) revealed that the process for barcode medication administration is that the patient's armband is scanned not the patient sticker that the nurses are using. The D.O.N. then stated that the expectation is that the workstation on wheels will be taken into the patient room to scan the patient armband and then scan the patient's medication. The D.O.N. stated that process has been a standing item at Nurses Meetings.

D. On 9/21/2022 at 2:35 PM a medication pass observation revealed RN-C preparing medications for Patient 1 in the hallway outside of Patient 1's room. RN-C was bare handed opening the medication foil package at the workstation. Upon entering Patient 1's room RN-C donned gloves without performing hand hygiene. RN-C then removed both green caps (disinfection caps contain 70% isopropyl alcohol to reduce risk of infections single use item) on the two lumens of Patient 1's PICC (peripherally inserted central catheter is a catheter inserted in the large central veins near the heart which is then used to give medication or liquid nutrition) line. After flushing each lumens with 20mL (milliliters) of normal saline RN-C then reapplied the same green cap on one lumen and connected the IV tubing to other lumen. RN-C then removed gloves and proceeded to the hallway without performing hand hygiene.

E. On 9/22/22 at 12:15 PM a medication pass observation revealed RN-A was preparing medications for Patient 4 in the hallway at the medication workstation. RN-A notified Licensed Practical Nurse (LPN-D) that (gender) was administering narcotics and insulin and would need LPN-D to co-sign. LPN-D confirmed that (gender) would cosign for medication. RN-A scanned a patient sticker to bring up patient MAR and scanned narcotics. LPN-D then cosigned for medication and walked down the hallway. RN-A then proceeded to Patient 4's room with workstation. RN-A scanned the insulin pen for administration and bypassed the co-signature screen. RN-A then drew up insulin to dose and did not have LPN-D verify the dose of insulin before RN-A administered it.

F. On 9/22/2022 at 12:15 PM an interview with RN-A during medication pass revealed that Patient 4 does not have an armband and that staff scanned a patient sticker instead.

G. Review of policy titled Distribution of Medications Review Date: 1/22 revealed: The person administering the medication identifies the patient by asking the patient his/her name or date of birth or other form of identification approved by the hospital.

H. Review of the policy titled Barcode Scanning and Medication Administration Review Date 1/22 revealed: For Formulary Bulk Medications: Every time the medication is administered to the patient, staff shall take the appropriate steps within the hospital's current electronic medication administration recording system to scan both the patient's identification barcode and the barcode on the product prior to administration of the product.

I. Review of the policy titled High Alert Medications and Labeling (Review Date 1/22) revealed:
All insulin administration will require a witness to verify the dose prior to administration. The witness will co-initial on the MAR (Medication Administration Record). Each patient will have their own insulin vial clearly labeled as such.

Based on record review, staff interview and patient interview, the facility failed to follow their policy and procedure for dressing changes, colostomy care and point of care blood sugar testing related to the frequent lack of all supplies necessary to provide the service to the patient per the orders/procedure.

Findings are:

A. On 9/20/22 at 2:05 PM, an observation of multiple dressing changes for Patient 1 following the bath. RN B and RN C were present in the room donned in gowns, masks, and gloves to perform the dressing change. Patient 1 has multiple wounds including: a midline abdomen surgical wound measuring 21 cm x 10 cm x 3 cm (centimeter); right breast measuring 3.3 cm x 2.2 cm x .3 cm ; left breast measuring 7.6 cm x 6.5 cm x .2 cmand right lower abdominal quadrant-brooke ileostomy. Dressing supplies included 4x4 guage pads; A&D tube of cream; Eakin Paste; Normal Saline for irrigation; Therabond; Thin Duoderm; Barrier wipes; Adapt Barrier Extenders; Ostomy bags; Lidocaine cream; Stoma Powder; kerlix; nuguage; antifungal powder; wafer and abd dressing. During the dressing change, when RN B and RN C were asked if they run out of supplies for the dressing change? RN B and RN C replied on occasion we do.

B. On 9/21/22 at 9:25 AM, the Clinical Services Coordinator provided a tour of the current supplies available for the day shift dressing change for Patient 1. It was found that the facility is lacking a bottle of nuguage.

C. On 9/20/22 at 8:15 AM, an interview with LPN E revealed that "there have been several times that the night shift has been short of supplies and had to figure out how to do the treatment with what was available." LPN E stated, "we leave notes for the supply person but there has been a turnover and they haven't gotten stuff we need."

D. On 9/26/2022 at 12:15 PM, an interview with the Assistant Director of Nursing (ADON) revealed that the facility was unable to obtain test strips for the Accucheck Performa (Point of Care Blood Sugar Machine) in March 2022. The ADON confirmed that staff had been trained to use the Accucheck Performa but when the facility was unable to obtain the test strips for the machine the nursing department decided to purchase a new glucose meter to perform the testing. The ADON was unsure if Lab Manager was notified that the facility could not obtain the needed test strips. The ADON stated that the Lab Manager was not involved in the purchase of the Reli On Machine (Point of Care Blood Sugar Machine) for the Nursing Department. The ADON stated that the Reli On Machine did not come with controls when purchased. The ADON stated that (gender) had to call the company to request controls. The company would only send 1 bottle of level 1 control. The ADON had RN-C call to request level 2 control from the company. The ADON was unsure of when this was done. The ADON stated that it was discovered that the staff were using the Performa machine controls to do testing on the Reli On machine. At that time the Performa controls were removed from the Nursing area and the ADON called the Reli On company to request more controls, again the company only sent 1 bottle of the level 1 control. The ADON confirms that the facility does not have proof of staff training with the Reli On machine. The ADON revealed that facility was unsure of where the instruction book for Reli On machine was located and that facility purchased a second Reli-on machine to obtain instruction book. Surveyor requested Instruction book for the Reli-On machine on 9/22/2022. Pamphlet for test strips was received. On 9/26/2022 Instruction book for the Reli On machine was available on arrival. Review of Instruction book for Reli On machine revealed that machine is a home use machine not for multiple patient use. Policy requested for Reli On machine. Facility unable to provide policy for machine use. Policy provided was for Accu-Chek Performa (Revised Date: 8/13/18).

E. An interview on 9/22/22 at 2:00 PM, the DON and Clinical Services Coordinator identified, that there has been some change over in staff that do the ordering, and we have ran into some difficulty securing the appropriate dressings for the patients. The Clinical Services Coordinator stated, "If we know we are short some supplies, we will send one of our staff to a pharmacy and get whatever we need. But, ultimately we try and need to have the supplies here for the staff."

Based on medical record review, observations and staff interviews, the facility failed to meet the ongoing nutritional needs for wound healing for 1 (one) of 10 sampled patients. Patient 1 (one) was accepted for admittance to facility in April 2022 with Diagnosis including significant open abdominal wounds, other skin pressure ulcers and colitis (a chronic inflammation of the digestive tract) requiring an Ileostomy (surgical opening for elimination of waste bypassing the large intestine/creating potential for malabsorption of nutrients).
Facility failed to provide a re-assessment of nutritional support needs after abrupt discontinuation of nasojejunostomy (food delivered to small intestine/bypassing the stomach) in September 2022, failed to provide documentation of communication with physician for nutritional intake information and ongoing lack of healing, failed to monitor the intake of protein supplementation provided to Patient 1 and failed to evaluate alternate interventions ( fortification of food) to meet patients low albumin (blood protein level).

Findings include:

A. Interview with Consultant Registered Dietitian and Dietary Manager on 9/22/2022 at 11:37am revealed that Patient 1's tube feeding was discontinued abruptly on 8/31/22 because nursing could no longer flush the tube as required. The Dietitian confirmed that on monthly facility visits, even though patient had been in facility 5 (five) months, she had not visited with Patient 1, had not looked at photos of multiple wounds and had not attempted any fortification (adding protein powder) to the foods Patient 1 would consume. The Tube feeding that had been administered daily to Patient 1 had provided 109 grams of protein for healing of wounds. Patient 1's Albumin level (blood protein level) was 2.5 - 2.8 grams upon admission to facility April - May 2022. Recent Albumin in August 2022 was 2.1 and 2.0 grams. (Normal Albumin levels are 3.5 - 5.5 grams). Dietitian requested tube feeding was increased on 8/15/2022 to help improve protein levels, nutritional levels and wound healing to provide 93.8 grams protein/day. When the tube feeding was discontinued on 8/31/2022, no re-calculation of protein needs for healing of wounds was documented by the Dietitian, nor any additional dietary interventions to replace the tube feeding intake.
( At current weight for Patient 1 and to meet current nutritional guidelines due to duration and number of wounds, size of wounds and depths of wounds, 1.5 grams of protein recommended for healing 88 kilograms (kg- metric weight unit) at 1.5 grams protein/kg = 132 grams protein per day. )

B. Dietitian confirmed that the oral supplements used for Patient 1 were delivered by nursing and no documentation of intake/acceptance was completed in the medical record. The meal intake percentages were started in August 2022 and consumption of meals was documented at 56-58% for lunch and supper only as patient always refused a breakfast meal tray and prefers to sleep in, creating patient nutritional needs to rely on oral supplementation for wound healing. NO additional type of meal offerings or late breakfast option were provided in lieu of Patient 1 refusal of breakfast. Patient 1 made low quality food choices and snacked on vending machine sweets (void of nutritional content/protein).

C. Nursing staff were to deliver a protein supplement three times daily to patient at 9:00am, 2:00pm and 8:00pm. The facility had NO documentation of the percentage of intake for these supplements. The current oral protein supplements (2 different products) provided to patient had differing amounts of protein:
Ensure - providing 9 grams of protein per 8 ounce bottle = 27 grams of protein per day from supplement if all 3 consumed (or 20% or needs at 132 grams/day).
and Ensure Enlive - providing 20 grams of protein per 8 ounce bottle = 60 grams of protein per day from supplement if all 3 consumed (or 45% of protein needs per day) .
Ensure Enlive was more difficult to receive from vendor and facility had no documentation of which supplement was provided.
Due to the facility not documenting the intake of the supplement and no verification of which supplement was sent, the correct actual protein intake for patient could not be accurately determined.

D. Dietitian confirmed had not been in contact with any of Patient 1's physicians directing medical care about wound healing or discontinuation of tube feeding. Dietitian related Nurse F a Registered Nurse (RN) was submitting information to physician. Interview with Nurse F on 9/22/22 at 12:04 pm related a verbal order over the phone was received from surgeon, but no medical record entry was completed to verify authentication of this order.

E. Facility documentation in medical record for wound care, photo documentation and observation of Patient 1 wound treatments on 9/22/22 at 2:10pm showed Patient 1 to have multiple Stage 2- Stage 3 wounds, with 2 large open wounds of the abdominal wall, large pressure ulcers under bilateral breasts, a deep tunneling wound in the groin area and a pressure area on the coccyx (tailbone). The circumference and total area of body percentage of wound involvement was not evaluated to determine protein needs to prevent any further protein energy malnutrition.
Patient 1 had enteral tube feeding providing 109 grams protein/day in addition to the oral supplements provided and meals and snacks, with discontinuation of the tube feeding Patient 1 was at best meeting 50-60% of protein needs daily, thus creating inability for patient to heal multiple wounds.

Based on record review, staff interview, observations and review of policy and procedures the facility failed to ensure staff had proper training with bedside glucose testing equipment. This failed practice has the potential to affect all patients the facility serves. The inpatient census on day of entrance was 5.

Findings are:
A. Review of Accu-chek Log sheet" revealed that control testing was not being completed on a routine basis.

B. Review of "Accu-Chek Log sheet" revealed that controls were out of range for machine staff would indicate that controls were not "ok" on log sheet but no follow up documented.

C. Interview on 9/26/2022 at 12:15 PM with the Assistant Director of Nursing (ADON) revealed that the facility was unable to obtain test strips for the Accucheck Performa in March 2022. ADON confirmed that staff had been trained to use the Accucheck Performa but when the facility was unable to obtain the test strips for the machine the nursing department decided to purchase a new glucose meter to perform the testing. ADON was unsure if Lab Manager was notified that the facility could not obtain the needed test strips. ADON stated that the Lab Manager was not involved in the purchase of the Reli On Machine for the Nursing Department. ADON stated that the Reli On machine did not come with controls when purchased. ADON stated that (gender) had to call company to request controls. The company would only send 1 bottle of level 1 control. ADON had RN-C call to request level 2 control from company. ADON was unsure of when this was done. ADON stated that it was discovered that the staff were using the Performa machine controls to do testing on the Reli On machine. At that time the Performa controls were removed from the Nursing area and ADON called the Reli On company to request more controls, again the company only sent 1 bottle of the level 1 control. ADON confirms that facility does not have proof of staff training with the Reli On machine. ADON revealed that facility was unsure of where the instruction book for Reli On machine was located and that facility purchased a second Reli-on machine to obtain instruction book.

D. Surveyor requested Instruction book for the Reli-On machine on 9/22/2022. Pamphlet for test strips was received. On 9/26/2022 Instruction book for the Reli On machine was available on arrival.

E. Review of Instruction book for Reli On machine revealed that machine is a home use machine not for multiple patient use.

F. Policy requested for Reli On machine. Facility unable to provide policy for machine use. Policy provided was for Accu-Chek Performa (Revised Date: 8/13/18).

Based on record review and staff interview, the facility failed to ensure all provider orders were signed off and implemented timely for 3 of 5 current patients (Patients 1, 2 and 4).

Findings are:

A. Review of Patient 2's medical record revealed the patient was admitted on 8/25/22. Pt 2's medical record had 2 pages of written admission orders dated 8/25/22 and timed 1650 by Physician Assistant J (PA J). The nursing staff on duty for 8/25/22 did not sign off the following orders: Admit to swing bed; activity as tolerated; regular diet; no labs; PT (physical therapy) & OT (occupational therapy) evaluate and treat; vital signs routine; daily weights; Tylenol 650 mg (milligram) po (per mouth) q (every) 4 hrs (hours) prn (as needed) pain/fever; Zofran 4mg ODT (orally disintegrating tablet) q 6 hrs prn N/V (nausea/vomitting); Miralax 17 GM po daily prn heart burn; Benadryl 25 mg q 6 hrs prn itching.

An interview with the DON on 9/22/22 at 2:15 PM verified that the Admission orders for Patient 2 were not signed off by the RN on duty. The DON said that the medication and therapy orders were taken care and implemented the next day.

B. Review of Patient 1's medical record revealed the patient received orders from the infectious disease physician on 8/16/22. Pt 1's medical record had 1 pages of written orders dated 8/16/22 and timed 110 by Doctor G. The nursing staff on duty for 8/16/22 did not sign off the following orders: Hold Zerbaxa (an antibiotic); Labs on 8/19/22-> CBC (complete blood count) with differential; CRP (C-reactive Protein measures the inflammation); procalcitanin (check for the level in your blood to determine possible sepsis); CMP (Complete Metabolic Profile); Hbs Ag ( a test to check for Hepatitis B); HCV Ab ( a test to check for Hepatitis C); Alkaline phosphatase isoenzymes (test to check for bone, liver disease); gamma GT (a test to check for liver or bile duct disease); diagnosis Hepatitis.

An interview with the DON on 9/22/22 at 2:15 PM verified that the infectious disease orders for Patient 1 were not signed off by the RN on duty. The DON said that the orders were taken care and implemented that day, they must of forgot to sign it off.

C. Review of Patient 4's medical record revealed the patient was admitted on 8/24/22. Pt 4's medical record had 2 pages of written admission orders dated 8/25/22 by Physician Assistant J (PA K). The nursing staff on duty for 8/24/22 did not sign off the following orders: Admit to swing bed; renal diet; CMP, CBC, UA (urine check); PT (physical therapy) & OT (occupational therapy) evaluate and treat; and medication's.

An interview with the DON on 9/22/22 at 2:15 PM verified that the Admission orders for Patient 4 were not signed off by the RN on duty. The DON said that the medication and therapy orders were taken care and implemented on the day of admission.

Based on staff observation and review of policy and procedures the facility failed to follow their infection control policies and procedures for handwashing. This failed practice has the potential to affect all patients the facility serves. Facility census on day of entrance was 5.

Findings are:
A. On 9/21/2022 at 11:50 AM medication pass observation revealed RN-B did not perform hand hygiene prior to handling medications or upon entering patient room with medications.

B. On 9/21/2022 at 11:50AM medication pass observation revealed RN-B administered patients' insulin injection without performing hand hygiene prior to or after insulin administration.

C. On 9/21/2022 at 2:35 PM medication pass observation revealed RN-C preparing medications for patient #1 in the hallway. RN-C was bare handed opening the medication foil package at the workstation. Upon entering patient #1's room RN-C donned gloves without performing hand hygiene. RN-C then removed both green caps (disinfection caps contain 70% isopropyl alcohol to reduce risk of infections, single use item) on the two lumens of patient #1's PICC (peripherally inserted central catheter is a catheter inserted in the large central veins near the heart which is then used to give medication or liquid nutrition.) line. After flushing each lumen with 20mL (milliliters) of normal saline RN-C then reapplied green cap on one lumen and connected IV tubing to other lumen. RN-C then removed gloves and proceeded to the hallway without performing hand hygiene.

D. On 9/22/2022 at 11:40AM observation of RN-A performing patient bedside glucose test (a lab test performed at the patient's bedside to obtain patients glucose(sugar) level). RN did not perform hand hygiene upon entering patients' room nor did RN don gloves prior to performing test that exposed her to patients' blood. After bedside glucose was complete RN did not perform hand hygiene prior to leaving patient room.

E. On 9/22/2022 at 12:15 PM medication pass observation revealed that RN-A did not perform hand hygiene upon entering patients' room prior to administering patients' insulin.

F. Review of policy titled Hand Hygiene (Last Review Date 8/20) revealed when to practice hand hygiene includes: before and after direct patient contact, after contact with body fluids, excretions, mucous membranes, non-intact skin or wound dressings, before preparing or handling medications.