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Based on observation, interview, and record review, the facility failed to implement Physician's orders for the wound care nurse to evaluate and propose a treatment plan for patients. The facility's wound care staff do not work on weekends, delaying the evaluations, recommendations, and treatment orders, placing any patient with wounds at risk for worsening wounds or infections from, delayed treatment, incorrect treatments, or no treatments.

Patients #4, 11, 12, 14, and 15 were admitted on the afternoon of 4/16/21, the admission nurses did not assess and obtain wound care orders for the care of the patients until the wound care nurse arrived on 4/19/21 (for patients # 4, 11, 12, and 15) and on 4/20/21, for patient #14.

Cross refer: A386

Based on interview, medical record review, and facility policy review, the facility failed to implement orders for 5 out of 5 patients reviewed with orders for the wound care staff to evaluate and propose a treatment plan. The patients were not evaluated on the weekend, delaying treatment or causing the patients to receive inappropriate treatment, placing patients at risk for worsening wounds and infections. (Patients #4, 11, 12, 14, and 15.)

Findings:

FACILITY POLICIES:

Review of the facility policy Wound Care Assessment and Reassessment (dated April 2015) reflected, "PURPOSE
To ensure the optimization of all wounds, and to monitor high risk patients for skin breakdown.

PROCEDURE

Upon admission the admitting RN will perform initial head to toe assessment to include wound photographs and documentation of the wound to include the size length, width, depth, and tunneling as well as the appearance of the wound to include any drainage or odor and complete the Braden Scale. Nurse will obtain wound care orders per hospital protocol. Nurse will complete Braden scale anytime patient has a change in condition, upon return from LOA [sic], and pictures of each wound will be taken weekly with any status change and within 24 hours of discharge.

Wounds such as dry skin tears or bruising will be photographed and placed on the ancillary photograph document, they will be noted on admission and picked up if there are any changes. If patient is wound free, pressure relieving equipment will be determined by the braden [sic] score.

Measuring guidelines:

Measure head to toe for length and left to right for width (anatomically correct).

Photographs should be taken with anatomical position in mind, if unable to the documentation provides location as well...Wound Care is a Monday thru Friday program at PAM Specialty San Antonio. The wound care team will perform their initial assessment on the next day or within the first 72 hours if admit arrives on the weekends."


PATIENT RECORDS REVIEW:

PATIENT #4's medical record review reflected an admission on 4/16/21 for respiratory failure secondary to traumatic brain injury status/post craniotomy.

Review of the 4/16/21 Physicians order reflected, "wound care staff to evaluate/propose treatment plan." There were no wound care instructions for the weekend staff to follow.

Review of the 4/19/21 Wound Care Orders reflected, "Site(s) Trach site, SX: Right lateral knee, Right lat thigh, right hip thigh, right hip.

SX (surgery) Sites; Q M-W-F (every Monday, Wednesday, and Friday) , apply skin prep and leave open to air cleanse with NS (Normal Saline), pat dry

Trach: cleanse with NS, pat dry apply [sic] calcium arginate with silver and optofoam with trach care by (RT)"


PATIENT #11's medical records review reflected an admission on 4/16/21 for Acute Chronic Respiratory Failure.

Review of the 4/16/21 Physicians order reflected, "wound care staff to evaluate/propose treatment plan." There were no wound care instructions for the weekend staff to follow.

Review of the 4/19/21 Wound Care Orders reflected, "#1 Cleanse with NS, pat dry, apply skin prep top with Mepilex drsg change Q T-T-S (every Tuesday, Thursday, and Saturday) and PRN (as needed)."


PATIENT #12's medical records review reflected an admission on 4/16/21 for COVID-19 pneumonia, tracheostomy, and permcath placement.

Review of the 4/16/21 Physicians order reflected, "wound care staff to evaluate/propose treatment plan." There were no wound care instructions for the weekend staff to follow.


Review of the 4/19/21 Wound Care Orders reflected,

"1) lower abdominal rash- apply topical triamcinolone

2) Left and right inguinal surgical sites- apply skin prep, cover each with small border foam, change Tues/Thurs/Sat

3) Left heel- unstageable pressure injury- apply betadine and cover with foam heel protector

4) Right heel- no wounds, provide preventive measures with Betadine and foam heel protector"


Review of the PATIENT #14's medical records reflected an admission on 4/16/21, with a Sacrococcygeal decubitus ulcer with infection and also has right gluteal subcutaneous abscess.

Review of the 4/16/21 Physicians order reflected, "wound care staff to evaluate/propose treatment plan." There were no wound care instructions for the weekend staff to follow.

A review, on 4/20/19 at 2:00 pm, of the patient's medical records revealed, the wound care staff had not provided a treatment plan. Patient #14's primary nurse, Staff #9, stated, "The wound care team was in with her today, they must not have entered their notes yet."


PATIENT #15's medical records review reflected an admission on 4/16/21 with a diagnosis of CVA, confusion, and seizures.
Review of the 4/16/21 Physicians order reflected, "wound care staff to evaluate/propose treatment plan." There were no wound care instructions for the weekend staff to follow.

Review of the 4/19/21 Wound Care Orders reflected,

"1) Cleanse with NS, paint with betadine, daily

2) Cleans with NS, pat dry, apply therahoney and mepilex, daily or PRN

3) Right heel paint with betadine- off load heel while in bed."


On the morning of 4/20/21, on the in-patient unit, when asked who does the assessment and writes the wound care orders, Staff #16, Wound Care Family Nurse Practitioner stated, "It would be me, that initiates the wound care orders ...I take pictures of the wounds ...I try to see the patients at least once a week. The nurses follow my recommendations." Staff #16 further stated, in part, the wound care nurses do not work on the weekends and that there are no wound care protocols for nurses to use as a guideline until the wound care nurse is able to assess and write orders for the wound care.

On the morning of 4/19/21, during an interview, when asked how the nurse knows what wound care should be given when there are no wound care orders, Staff #5, RN stated, "I get it in report."

On the morning of 4/20/21, during an interview, when asked what orders are used if the patient is admitted late Friday and the wound care staff have not assessed and written wound care orders, Staff #17, ICU RN stated, "We would do wet to dry or look to see what was done at the previous facility and follow that."

On the afternoon of 4/20/21, during an interview in the administrative offices Staff #4, CEO stated, "The nurses have to do the assessment."

On the afternoon of 4/20/21, during an interview in the administrative offices , when informed the nurse received the wound care instruction in a nurse to nurse report, not from physician's orders, Staff #2 , CNO stated, "It shouldn't be from report, they have to get an order to continue the previous facility's wound care orders." When asked why the wounds were not assessed on admission, Staff #2 stated, "There aren't any wound care nurses on the weekend, that's how it was when we took over the place."

On the afternoon of 4/20/21, during an interview in the administrative offices, Staff #1, Director of Quality confirmed the findings and stated, "We are already starting a new process."

Based on observation, interview, and record review, the facility failed to provide care in a clean and sanitary environment when patient care items were not disinfected between patients and hand sanitizers were left with debris, creating an environment for the possible spread of infectious diseases.

Findings:

An observation on 4/19/21 at 10:30 am, revealed an unidentified nursing staff taking the portable blood pressure machine from Patient #16, on contact isolation for Staph Capitis, into Patient #17's room, on Contact isolation for Pseudomonas Stutzeri and then back again into Patient #16's room. The staff member did not disinfect the portable blood pressure machine between the patients.

When informed, Staff #1, Quality Director stated, "The equipment should be cleaned between all patients. Those are different organisms, even if they are the same organism, the equipment still needs to be cleaned between patients. They could get re-infected."


An observation on 4/21/21 at 2:00 pm, during a tour of the 100 hall patient rooms with Staff #19, Infection Control Nurse, revealed 6 hand sanitizers, located outside the patient's rooms with copious amounts of dark brown and yellow residue stuck to the underside of the dispensers. The hallway is the main entrance onto the patient care units for staff and visitors. Staff #19 confirmed the findings and stated, "I'll get housekeeping right on it."


Review of the facility provided policy CLEANING OF PATIENT EQUIPMENT (last reviewed July 2017) reflected in part,

"PURPOSE

To provide a guideline for all staff to ensure the proper cleaning and disinfection of all non-critical equipment used in patient care areas to prevent the spread of disease between patients.

POLICY

Equipment used during the care of patients should be thoroughly cleaned and disinfected on a scheduled and as needed basis to prevent the spread of disease between patients ...

Patient Care Equipment

Cleaning

CONTACT TIMES (TIME MUST REMAIN WET)

Non Bleach Wipes -2 minutes

Bleach Wipes -4 minutes ...Vital Sign Machines Between patient use..."


Review of the facility policy Terminal Cleaning of Patient Rooms (last reviewed July 2017) reflected, "...2. Environmental surfaces (e.g., floors, and walls) may be involved in transmission of microorganisms. Environmental Services staff will focus on surfaces that may serve as important reservoirs of microbial contamination. This would include those that are touched frequently (e.g., bed rails, doorknobs, lavatory surfaces, call lights, and cords) using an Environmental Protection Agency (EPA)-registered disinfecting agent ..."