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LAWNWOOD REGIONAL MEDICAL CENTER & HEART INSTITUTE 1700 S 23RD ST FORT PIERCE, FL 34950 June 15, 2017
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the facility failed to ensure the nursing staff provided the necessary care and services for wound care for 2 of 10 sampled patients (Patient # 1 and # 2) as evidenced by the staff failure to perform the prescribed wound care as ordered and failed to use acceptable standards of nursing practice for infection control to prevent cross contamination during wound care.

The findings included:

1) Review of the clinical record for Patient # 1 disclosed the patient was admitted to the facility on [DATE] with a diagnosis of Chronic right foot complex wound, osteomyletitis. The patient also has a history of receiving intravenous antibiotics for bilateral Diabetic foot ulcers, amputations of the 2nd, 3rd and 4th toes on the right foot. The patient is currently on contact isolation. A 06/13/17 physician order, prescribed for the patient to receive Wet to Dry dressing with Betadine packing daily and as needed.

An observation of the wound care for Patient # 1 was conducted on 06/14/17 with Staff A and Staff C, Registered Nurses. The Quality Coordinator was also present during the wound care observation. Staff A donned two pair of gloves and proceeded to remove the old dressing from the left and right foot of Patient # 1. Upon removing and discarding the old dressings on both feet, the nurse removed one pair of the gloves she had donned. She then donned another pair of gloves over the first pair and proceeded to clean around the left foot wound and then the right foot wound with Normal Saline Solution (NSS) soaked gauze. She then obtained another NSS soaked gauze and proceeded to clean the inside of the wound on the left foot. She obtained another NSS soaked gauze and proceeded to clean the inside of the wound on the right foot. She then used a Betadine soaked gauze and proceeded to clean inside the right foot, padded around inside the wound twice with the Betadine soaked gauze. She went to the left foot and used a Betadine soaked gauze and wiped around inside surface of the wound and padded the inside of the wound three times with the gauze. She packed the wound on the left foot with gauze saturated with NSS. She then packed the wound on the left foot with two gauze soaked with NSS. She then wrapped the left wound with Kerlix, double folding an area of the Kerlix over the wound and proceeded to wrap Kerlix around the foot and ankle. Staff A then applied Kerlix to the right foot dressing as well. The staff continued to alternate between two wounds using the same gloves, cleaning, dressing and packing the wounds. The staff did not utilize acceptable standards of practice for wound care and infection control or perform the entire dressing care on one wound. She did not remove her gloves and perform hand hygiene before proceeding to perform wound care on the second wound to prevent cross-contamination between wounds.

An interview was conducted with Staff A, following the observation at 12:55 PM to review, the nurses technique of alternating between wounds with the same gloves and the enhanced possibility of cross contamination of infections with the method utilized by the nurse.

Another interview was conducted on 06/14/17 at 12:57 PM with the Clinical Coordinator, Staff B, who confirmed the accepted practice for wound care on multiple wounds is to perform one wound care dressing at a time, remove your gloves and wash your hands before proceeding to the second wound.

After reviewing the electronic record and the prescribed wound care, the wound care observation revealed the nurse did not perform the prescribed wound care. The nurse packed the wound with Normal Saline Solution dressing, not the Betadine packing as prescribed.

An interview was conducted on 06/14/17 at 2:25 PM with the Quality Coordinator, who was also present during the wound care observation. She confirmed that the nurse did not perform the prescribed wound care. The nurse provided Normal Saline Solution packing to the wounds instead of the prescribed Betadine packing, "she cleaned with Betadine".

2) Review of the clinical record for Patient # 2 disclosed that the patient was admitted on [DATE] from home with a chief complaint of fever. The patient was admitted with eight (8) wounds/skin issues and 5 of the wounds are identified on the patient's bilateral lower extremities which are black in color, gangrene located on the Right Heel, Left Foot, Left Medial Leg and Left Lateral Leg. On 03/21/17 an order was obtained for daily wound care to the bilateral lower extremities of painting wounds with Betadine then wrap with cast padding and spandage.
Review of the wound care provided from 05/13 through 05/29/17, revealed that the facility was unable to provide evidence the wound care for the lower extremities was performed as prescribed on 5 of 16 times on 05/14, 05/15, 05/16, 05/19 and 05/23. During the simultaneous review of the electronic record and interview with the Vice President Quality Management, Quality Coordinator and the Clinical Coordinator, Progressive Care Unit (PCU), they confirmed on the above five dates, they were unable to locate evidence that the wound care was performed by the nurses.

An interview was conducted on 06/15/17 at 10:50 AM with the Wound Care Nurses revealed that they were initially performing the Wound Vac wound care three times a week and the other wound care for the hip and lower extremities wounds were performed by the floor nurses. The lower extremity wounds were dry with eschar covering. The WCN stated the patient's legs and toes were extremely dry with eschar and looked like her toes, etc. "would fall off at any moment".