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Based on interview, record review, and review of the facility's Bathing and Hygiene Policy, it was determined the facility failed to ensure two (2) of ten (10) sampled patients, Patient #8 and Patient #10 received baths as outlined by the facility.

The findings include:

Record review of the facility's Bathing and Hygiene Policy, revised 01/11, revealed all patients/residents will receive a completed bed bath daily. Nursing assistants and staff will check the bath schedule at the beginning of the shift to see which patient/residents were due for complete baths and which patients/residents were due for a partial baths. The nursing staff were to document bath hygiene in the medical record.

Record review of the bath log for Patient #8 revealed he/she was to receive a bath on Tuesday, Thursday and Saturday evenings.

Record review of the hygiene assessment, dated 07/11/12 through 07/26/12, revealed Patient #8 received a full bath on Wednesday, 07/11/12. Patient #8 did not receive another full bath until Monday, 07/16/12 and did not receive another full bath until the following week Tuesday, 07/24/12, eight (8) days later.

Record review of the bath log for Patient #10 revealed he/she was to receive a bath on Tuesday, Thursday and Saturday evenings.

Record review of the hygiene assessment, dated 06/29/12 through 07/26/12, revealed Patient #10 received a full bath on Saturday 07/04/12, on Monday 07/06/12, Wednesday 07/08/12, Saturday 07/11/12 and on Monday 07/13/12. Patient #10 did not receive another full bath until six days later, on Sunday 07/19/12. Then, seven days later, on Sunday 07/26/12.

Interview with Certified Nursing Assistant (CNA) #2, on 07/26/12 at 5:45 PM, revealed she reviews a list for patients who need a bath. CNA #2 stated she documented baths in the computer. She stated she tried to offer a bath to the patient then document under the comments section in the computer. If the patient did not receive a bath, the CNA then reported to the next shift. If the patient refused or did not receive a bath on their scheduled day, the CNA was to then report the information to the nurse or the Unit Manager.

Interview with the 5 C Unit Manager, on 07/26/12 at 4:58 PM, revealed the bathing staff were to do baths on the patients scheduled days. The Unit Manager stated if a patient refused or did not receive a bath; the CNA was to report to the nurse. If the bath issue was not resolved then the Unit Manager would find a way to resolve the concern.

Based on observation, interview, and facility policy review, it was determined the facility failed to follow an infection control program for one (1) of ten (10) patients as evidence by staff not disinfecting hands after removal of gloves while doing wound dressing changes and replacing a used dressing into the wound of Patient #9.

The findings include:

Review of the Hand Hygiene Policy, revised 06/11, revealed the purpose for hand hygiene was to remove transient microorganism from hands by following the CDC or the WHO hand hygiene guidelines. Hand hygiene will be performed as follows; after the removal of gloves.

Observation of the Nurse Practitioner assessing Patient #9's wound to her right eye, on 07/26/12 at 3:40 PM, revealed the Nurse Practitioner removing an eye dressing to the right eye and then replacing it back into the eye.

Interview with the Nurse Practitioner, on 07/26/12 at 3:40 PM, revealed she placed the dressing back into the right eye of Patient #9 because she did not want the eye socket to become dry.

Observations of the Nurse Practitioner completing a skin assessment and dressing change, on 07/26/12 at 4:02 PM, revealed the Nurse Practitioner applied two pairs of gloves on. She touched Patient #10's soiled brief, then removed the old dressing from Patient #10's coccyx. The Nurse Practitioner removed her gloves and placed new gloves on. She then cleaned the wound to the coccyx area and reassessed Patient #10's wound. The Nurse Practitioner then removed her gown and gloves and washed her hands.

Interview with the Nurse Practitioner, on 07/26/12 at 4:19 PM, revealed she was aware when she removed her gloves, she needed to turn them inside out and then wash her hands between glove changes. The Nurse Practitioner stated they wash their hands to prevent the transfer of any germs to the patients.

Interview with 5 th floor Nurse Manager, on 07/26/12 at 5:45 PM, revealed when staff members remove their gloves they were to wash their hands. The Nurse Manager stated they wash their hands to prevent the spread of infection. The Nurse Manager further stated dirty dressings were not to be placed back into a wound because they are re-infecting the wound.