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Based on observation, interview and facility policy review, the facility failed to follow current standard of practice for infection control and failed to provide a patients' right to receive care in a safe setting during wound dressing change of 1 of 2 sampled patients. Patient # 2.


Patient # 2

admitted on [DATE] with a pressure injury to coccyx area.

During an interview with Patient # 2 on 7/23/2020 at 10:25 AM, with Patient # 2 stated he has a colostomy and is paraplegic. When asked if he was turned or repositioned from side to side during the night, Patient # 2 replied; "not at all", this is the first time I got tuned that you are here".

Review of wound care nurse specialist assessment reads: Patient presents with coccyx wound measuring 6 cm. x 4 cm. x 1 cm. at deepest.

An observation during a wound dressing change on 7/23/2020 at 10:34 AM in the presence of the Staff F- Clinical Leader and Assistant VP Nursing. Staff E and Staff G both Registered Nurses (RN) entered Patient # 2 room in order to perform a wound dressing change. Staff E, an RN immediately donned a pair of gloves and explained to Patient # 2 what she was about to do. Staff E, RN failed to wash hands or perform hand hygiene prior to donning the gloves. Staff E assisted by Staff G turned Patient # 2 on to his right side to expose his sacral area. The patient requires two staff members assistance to turn secondary to [DIAGNOSES REDACTED]. Two wound dressings were observed at the patients' sacral area. Staff E removed old dressing from the coccyx wound. There were brownish colored exudates from the old dressing. Using the same pair of gloves, Staff E, RN proceeded to open a box of sterile gauze. Staff E, RN poured a saline solution to soak the gauze. Using same contaminated gloves, Staff E, RN cleansed the sacral wound with the normal saline soaked gauze 3 times, then patted it dry. Patient has an open, Stage III pressure wound in coccyx area, edges are irregular with approximately 60% maceration on wound edges, and with granulation tissue. Using same contaminated gloves, Staff E used a scissor to cut the medicated wound dressing, then applied clean dressing over the wound bed. With the same contaminated gloves, Staff E, RN removed old dressing from another wound site on left ischium. Noted a large excoriation approximately 3 inches long on left buttocks. Area is bright red with intact skin. Staff E, RN replaced gloves, no hand hygiene or hand washing, then proceeded to don another pair of gloves. Staff E, RN applied barrier cream to both areas on left ischium and left buttocks. Staff E gathered all wound dressing supplies and discarded in the trash can. Staff E, RN failed to sanitize the scissor and left it on the bedside table. Staff E, RN removed gloves and exited room without washing her hands or performing hand hygiene.

During an interview on 7/23/2020 at 11:51 AM, with Staff F stated she is the Clinical Leader of the unit. When asked if she observed anything unusual during the wound dressing change on Patient # 2, Staff F, replied; "none, everything was fine".

During an interview on 7/23/2020 at 11:52 AM, with Staff E stated she is a Registered Nurse (RN) and the primary nurse of Patient # 2. When asked if she could have improved something during the wound dressing change on Patient # 2, Staff E, RN replied; " yes, I should have changed my gloves".

A review of the facilty's policy "Review of Wound Care Management Policy with Guideline # GL-BI-SW-004" Reviewed: July 2017 shows:
Purpose: The purpose of this guideline is to promote wound healing and / or prepare full thickness wounds for surgery, as evidenced by adequate circulation, absence of infection, re-epithelialization within anticipated time frame, and satisfactory cosmetic results.
Page 2 of 9 of the policy reads:
C. Routine dressing procedure.
Remove old dressings, taking care not to cause bleeding, damage to underlying tissue or remove synthetic dressing. Adhered dressing may be wet down. Dispose immediately into covered biohazard receptacle.
Change sterile gloves.
Wash wounds with old topical ointments with cleansing solution. Do not rinse.
Change sterile gloves.
Post Procedure Care: Item # 6 reads: Wash hands.

A review of the facility's policy "Review of Hand Hygiene Policy and Procedure: Policy # CP09.202". Approved on 2/18/2019 shows:
Page 2 of 3 of the policy reads:
Core Procedure:
1. Hand hygiene is required:
A. Prior to entering patients' room.
B. Before direct contact with any patient.
C. Between procedure on the same patient.
D. Prior to donning and after doffing gloves.
E. As leaving patient room.
Page 3 of 3 of the policy reads:
VIII - hand hygiene practices are monitored by each patient care unit staff and other departments.
XI - Supervisor / management staff members are responsible to enforce and monitor their employee's compliance with this policy.