HospitalInspections.org

Based on the review of medical records (MR), the hospital's Wound Care Protocol, facility policies and procedures, facility Wound Care/Skin Care Protocol and interviews it was determined the facility failed to ensure the staff provided wound care according to physician orders, completed wound assessments and notified the physician of patients' wound deterioration/new wounds.

Findings include:

Refer to A 392 for findings.

Based on review of medical records (MR), facility policies, and interviews, it was determined the facility failed to ensure the staff:

1. Educated the patient on pressure relief strategies and techniques per facility policy.

2. Documented the patient's oral intake to optimize the patient's nutritional status for wound healing.

3. Documented the correct wound type.

4. Followed the physician's orders for wound care.

5. Performed wound assessments and measured wounds per policy.

This affected 5 of 5 medical records (MR) review with wounds including Patient Identifier (PI) # 2, PI # 3, PI # 1, PI # 4, PI # 5, and had the potential to negatively affect all patients served by this facility.

Findings Include:

Policy: Wound Assessment, Prevention, and Documentation
Policy Number: 2
Date: 7/20/18

Purpose:
1. To improve patients' skin integrity through timely and consistent clinical practices for assessment and prevention of wounds.
2. To ensure standard documentation related to the assessment of skin and wounds.
3. To facilitate both accuracy in wound assessment and quality reporting...

Policy:
All patients admitted to the hospital will be screened within 8 hors for risk of skin breakdown and for alteration in skin integrity by a registered nurse.

For a Braden score of 18 or less, the Skin Breakdown Prevention Protocols (as described in this policy) will be initiated and incorporated into the plan of care. Each patient's wound care will be under the direction of a physician.

I. Assessment
An RN (Registered Nurse) will inspect each patient's integument daily, weekly and as often as indicated.

1. The Braden Scale is used to assess all patients at risk for skin breakdown...

2. Pressure injuries are noted in the record upon discovery...

...C. Pressure injuries will be staged, measured, and photographed in accordance with the wound treatment plan, but no less than weekly.

D. Within 2 days before discharge a final complete assessment is conducted, including descriptions, staging, measuring, and photography...

4. Skin around medical devices will be assessed at least twice per day for signs of infection, skin break down, and pressure...

...III. Documentation
1. Documentation of Assessment: The RN will describe the wound precisely.

A. Wound label: Assign a number (procedure-related wounds) or a letter (pressure injury or other alterations in skin integrity) to note the existence of location of a wound.

B. Measurement: Stage 2 and greater pressure injuries, and other wounds as applicable will include the following documentation: Size: Length, Width, and Depth should be recorded in centimeters (cm) on admission or discovery, weekly and at discharge...

C. Exudate (drainage): indicate amount, type, color, and odor of exudate.

D. Wound base: State the color, type, and proportion of tissue located in the wound base...

E. Wound edges...

F. Condition of surrounding skin (periwound)...

G. Signs and symptoms of infection...

2. Daily documentation of skin and wound inspection completed by an RN will include any of the following , if present:

A. Skin condition

B. Dressing integrity

C. Description of wound drainage, odor pain, signs of inflammation or infection, if present

...4. Weekly documentation will include:

...VI. Prevention and Basic Treatment...the following prevention and basic treatment techniques should be included as appropriate:

1. Determine and Provide Appropriate Support Surfaces for Pressure Relief.

A. Evaluate need for speciality surface for high risk patients with impaired bed mobility...

...2. Manage patient positioning to minimize risk of skin breakdown.

A. Educate patient regarding the importance of self-initiated movement to reduce pressure through weight shifts and repositioning.

B. Establish a regular repositioning schedule for patients who are unable to manage pressure relief independently or need assistance with cueing...

F. Document repositioning, to include frequency and position adopted appropriate to individualized plan.

...5. Promote patient involvement in prevention of skin breakdown.

A. Provide education to patient and family on pressure relief strategies and techniques as appropriate...

6. Provide systemic support for wound healing.

...E. Optimize the patient's nutritional status.

1. PI # 2 was admitted to the facility on 2/14/19 with admitting diagnoses of Spinal Cord Compression and Lung Cancer with Bone Metastasis.

Review of the IView (Interactive View) notes on 4/3/19 revealed the following dates the Braden Score was documented as 18 or below:

2/14/19, Braden Score 12
2/15/19, Braden Score 13
2/16/19, Braden Score 14
2/17/19, Braden Score 15
2/19/19, Braden Score 18
2/20/19, Braden Score 18
2/21/19, Braden Score 16
2/22/19, Braden Score 18
2/23/19, Braden Score none recorded
2/24/19, Braden Score 17
2/25/19, Braden Score 16
2/26/19, Braden Score 16

Review of the IView notes on 2/14/19 at 6:43 PM revealed the Skin Care Protocol documentation as follows: "Order entered secondary to documenting a Braden Score of less than 18."

EI (Employee Identifier) # 2, Nurse Manager, was asked for the skin care protocol on 4/3/19 at 1:00 PM. EI # 2 provided the surveyor with a form titled Wound Care and Skin Treatment Protocol.

Review of the Wound Care and Skin Treatment Protocol revealed no documentation for a Stage 4 wound or an unstageable wound. The surveyor then asked for documentation of the protocol for the Stage 4 and an unstageable wounds. EI # 2 replied by stating "there is no protocol for those. The physician is to be called."

Review of the pictures taken on 2/14/19 at 11:16 AM revealed a small open area at the top of the wound and slough/eschar and redness covering the rest of the sacral area.

Review of the nursing documentation dated 2/14/19 the nurse documented the following in IView:

Skin Symptoms: Ulcers/Lesions, Skin Integrity: Intact, with abnormalities.
Procedure: Coccyx Pressure Injury:
Inc (incision)/Wnd (wound) Description/Assess: Edges separated, Granulated
Drainage: Scant
Exudate Odor: Foul
Signs of Infection: Localized
Improved Condition: yes

Further review of the 2/14/19 nursing note revealed no documentation the wound was measured or the physician was notified of the pressure ulcer.

Review of the 2/15/19 nursing note revealed a wound assessment at 6:53 AM. The nurse documented Coccyx Pressure Injury:
Wound Specialist? Yes, Pressure Ulcer on Admission: yes.

Review of the narrative section of the IView note dated 2/15/19 at 6:50 AM revealed the nurse documented "Unstageable due to slough and/or eschar."

Review of the nursing documentation in IView dated 2/15/19 at 1:15 PM revealed under the wound section: Coccyx Pressure Injury: Inc/Wnd Description/Assess: Edges separated.
Drainage: Scant
Exudate Odor: Foul
Signs of Infection: Localized
Improved Condition: No.

Review of all the nursing progress notes dated 2/14/19 to 2/15/19 revealed no documentation the physician was notified of the slough/eschar on the wound, no documentation of wound measurements and no documentation of a physician order on 2/15/19 for dressing changes and no documentation wound care was performed.

Review of the physician order dated 2/15/19 at 2:02 PM revealed the following order: Wound - Stage 2 revealed the following documentation:
"q (every) 2 day Sacral Area, Clean wound. Pat dry. Apply Optifoam dressing."
The surveyor asked EI # 2 was the wound to be cleaned once every 2 days or twice a day and what was the wound to be cleansed with? EI # 2 responded by stating " it is to be cleaned twice a day and it does not state with what."

Review of the nursing documentation in IView dated 2/16/19 revealed no documentation by a nurse of a wound assessment, wound measurements or wound care for the day shift or the night shift.

Review of the nursing documentation in IView dated 2/17/19 at 9:00 PM the nurse documented under skin integrity skin was " Intact, no abnormalities." Further review of the note revealed no documentation on the day shift or the night shift of a wound assessment, wound measurements or wound care.

Review of the physician orders within the medical record revealed an order dated 2/18/19 at 8:00 PM for Santyl to be applied Bid (twice a day) to sacral area.

Review of the IView nursing notes dated 2/19/19 at 8:50 AM the nurse documented Coccyx Pressure Injury:
Dressing: Changed, Dry,Foam.
Description/Assess: Necrotic tissue.
Cleansing/Irrigation: Cleansed with Wound Cleanser.
Drainage: Odor free, Sanguineous
Exudate Odor: None
Wound Edges: Defined
Surrounding Skin: Erythema
Signs of Infection: None
Debridement: Santyl applied at this time.
Wound Specialist: Yes

Further review of the 2/19/19 nurses note revealed no documentation of a wound measurement.

Review of the IView nursing note documentation dated 2/20/19 revealed no documentation of a wound assessment,wound measurements or wound care to the coccyx for either the day shift nor the night shift.

Review of the 2/21/19 nursing note revealed no documentation of wound care performed on the day shift.

Review of the IView nursing note documentation dated 2/21/19 at 8:15 PM revealed the nurse documented:
Cleansing/Irrigation: See Below.
Further review of the 2/21/19 nurses note revealed no documentation of what was used to clean the wound.

Review of the IView nursing note documentation dated 2/22/19 at 9:07 AM revealed the following wound documentation: Coccyx Pressure Injury:
Dressing: Changed.
Description/Assess: Necrotic tissue, eschar.
Cleansing/Irrigation: Cleansed with Wound Cleanser.
Drainage: See Below. The nurse documented in a narrative Drainage: Odor Free, Scant, Serosanguineous.
Signs of Infection: None
Debridement: Santyl.

Review of the 2/22/19 nursing note at 10:00 AM revealed no documentation as to what type of dressing was applied and no documentation of wound measurements. Further review revealed no documentation by the night shift of a wound assessment, wound care or measurements.

Review of the nursing documentation dated 2/24/19 revealed no documentation by day shift staff or the night shift staff of a wound assessment, wound care or wound measurements.

Review of the picture taken on 2/25/19 one day prior to discharge revealed the wound to the coccyx had increased in size since 2/15/19. There was no documentation of the wound size on 2/15/19, the picture showed a small open area to the top portion of the coccyx area only. No measuring tape was used during the picture. On 2/25/19 the picture showed a large open area to the entire sacral area measuring 6 cm (centimeters) X 5.2 cm.

Review of the nursing documentation date 2/25/19 the nurse documented wound measurements of the coccyx as 6 cm (centimeters) X 5.2 cm. Further review of the medical record revealed the measurements taken on 2/25/19 were the only measurements documented from 2/14/19 to 2/25/19.

Review of the medical record revealed no documentation the physician was notified of the increase in size of the wound.

Review of the nursing documentation dated 2/26/19 revealed no documentation of a wound assessment, wound measurements nor was there documentation of wound care.

The patient was discharged home with home health on 2/26/19.

Review of the discharge summary revealed no documentation of the wound to the coccyx area or what treatment has been performed while in the hospital.

Review of the Home Health admission oasis note dated 2/27/19 at 12:30 PM revealed the patient had an Unstagable Pressure Ulcer/Injury to the sacrum measuring 10 cm (centimeters) by 10 cm by 1 cm. The pressure ulcer was described as unstageable with necrosis and purple in color.

An interview was conducted on 4/4/19 at 11:30 AM with EI # 2 who confirmed the above mentioned findings.

2. PI # 3 was admitted to the facility on 3/28/19 with an admitting diagnosis of Major Multiple Trauma.

On admission the nurse documented at 1:37 PM the patient had an unstageable pressure wound due to a deep tissue injury and was located on the buttocks.

Review of the IView notes printed on 4/3/19 revealed the following dates the Braden Score was documented as 18 or below:

3/28/19, Braden Score 16
3/30/19, Braden Score 15
3/31/19, Braden Score 16
4/1/19, Braden Score 16
4/2/19, Braden Score 16
4/3/19, Braden Score 16

Review of the physician order dated 3/28/19 revealed and order for Skin Care Protocol. Order entered secondary to documenting a Braden Score less then 18.

Review of the Pre-Admission Information dated 3/28/19 revealed the patient fell in his/her yard and fractures occurred of the right humeral neck. Further review revealed under the wound care section was documented wounds/incisions: yes, Wound Description: surgical incision to right shoulder and right hip both with staples. There was no documentation of an Unstagable wound to the buttocks or bilateral heels.

Review of the IView nurses note dated 3/28/19 at 1:37 PM revealed the following wound documentation: Buttocks Pressure Injury:
Pressure Ulcer Stage: The nurse documented "See Below."

Review of the documentation of the 3/28/19 narrative for the pressure ulcer revealed the wound was unstageable due to deep tissue injury. Further review revealed no documentation as to where the unstageable pressure ulcer was located on the buttocks, nor was there documentation of wound care or wound measurements.

Review of the physician orders dated 3/29/19 revealed an order written for Balsam Peru-Castor Oil Topical (Venelex) Ointment BID. Apply to both heels as ordered. Assess heels for changes with applications.

Review of the Flowsheet Print Request forms dated 3/29/19 revealed no documentation of a wound assessment, wound measurements or wound care.

Review of the Flowsheet Print Request forms dated 3/30/19 review revealed at 9:33 AM the nurse applied ointment per the physician order and at 11:27 AM the nurse applied paste/powder. Further review revealed no documentation of an order for the paste/powder nor documentation as to why the wound care was performed twice that morning.

Review of the IView nursing documentation dated 3/30/19 at 3:01 PM revealed the following documentation:

Buttocks Pressure Injury:
Dressing: Paste/Powder/Beads.

Review of the physician orders in the medical record revealed no documentation of a Physican order written for Paste/Powder/Beads.

Review of the IView nurses note dated 3/31/19 at 9:33 AM revealed the following wound documentation:
Buttocks Pressure Injury:
Dressing: Ointment.

Review of the nurse note dated 3/31/19 revealed no documentation of the actual wound care, only ointment was applied and no documentation of wound measurements.

Review of the IView nurses note dated 4/1/19 revealed the nurse documented under Skin Integrity "Intact, no abnormalities."

Review of the Flowsheet Print Request form dated 4/1/19 to 4/2/19 revealed no documentation of wound care, wound assessment or measurements.

On 4/4/19 at 10:15 AM EI # 2 was asked for the initial order for wound care. EI # 2 responded by stating " no order was written."

On 4/4/19 at 1:20 PM EI # 2 was asked where on the buttocks was the wound located EI # 2 responded by stating " it was not on the buttocks it was on the sacrum."

On 4/4/19 at 12:00 PM EI # 2 was asked if any wound measurements were found in the medical record. EI # 2 responded by saying " I could not find any."

An interview was conducted on 4/4/19 at 5:14 PM with EI # 2 who confirmed the above mentioned findings.



40119

3. PI # 1 was admitted to the facility on 2/4/19 with the diagnoses of Right Femur Fracture and Left Wrist Fracture Status Post Fall.

Review of the IView Print Request notes revealed the following dates the Braden Score was documented as 18 or below:

On 2/4/19, Braden Score 17
On 2/6/19, Braden Score 15
On 2/7/19, Braden Score 17
On 2/8/19, Braden Score 15 at 7:47 AM and 16 at 9:43 AM
On 2/9/19, Braden Score 16
On 2/10/19, Braden Score 15

Review of the Physician Orders dated 2/4/19 revealed physician's orders for "Skin/Wound Assessment" and "Skin Care Protocol" with comment of "order entered secondary to documenting a Braden Score less than 18."

Review of the IView Print Request for 2/4/19 at 6:04 PM through 2/6/19 at 7:00 PM revealed no documentation of the "patient position/turn patient."

Review of the IView Print Request for 2/7/19 at 7:00 AM through 2/7/19 at 6:00 PM revealed no documentation of the "patient position/turn patient."

Dietary

Review of the Physician Orders dated 2/4/19 at 5:13 PM revealed a physician's order for Megestrol (appetite stimulant) 40 mg (milligrams)/ml (milliters) daily.

Review of the Physician Orders dated 2/5/19 at 1:35 PM revealed a physician's order for "Dietary Supplements" of Ensure TID (three times a day) with meals and "Encourage Fluids".

Review of the Plan of Care dated 2/5/19 at 1:35 PM revealed a goal of "Achieves Optimal Nutritional Status" for nutrition.

Review of the Intake and Output dated 2/5/19 through 2/11/19 revealed no documentation of an "oral intake" for:
2/5/19 7:00 AM to 2/6/19 7:00 PM
2/7/19 7:00 AM to 7:00 PM
2/8/19 7:00 AM to 2/9/19 7:00 AM
2/9/19 7:00 PM to 2/11/19 7:00 AM

Further review of the Intake and Output dated 2/5/19 through 2/11/19 revealed no documentation the dietary supplement (Ensure) was administered or consumed by the patient for the dates of 2/5/19 to 2/8/19 and 2/9/19 7:00 PM to 2/11/19. The total intake of 400 ml was documented for the entire hospitalization.

Review of the IView Note(s) revealed the following documentation for the percentage of breakfast, lunch, and dinner:
On 2/5/19, no documentation of breakfast, lunch, or dinner
On 2/6/19, breakfast 50% , lunch 50%, no documentation for dinner
On 2/7/19, breakfast 25%, lunch 50%, no documentation for dinner
On 2/8/19, no documentation of breakfast, lunch, or dinner
On 2/9/19, breakfast 25%, lunch 25%, dinner 25%
On 2/10/19, no documentation of breakfast, lunch, or dinner
On 2/11/19, breakfast 0%

Review of the IView Note dated 2/5/19 at 1:35 revealed dietitian evaluation with documentation of oral intake goal of "50-75 % (percent)" for meals.

Review of the IView Note dated 2/7/19 at 2:21 PM revealed dietitian documentation to "Encourage PO (oral) feedings."

Review of the MR from 2/5/19 through 2/11/19 revealed no documentation the physician was notified of the patient not meeting oral intake goal for meals of 50-75 %.

The facility staff failed to document the physician ordered Ensure was administered and consumed three times a day, document oral intake to encourage fluids per the physician's order, documented the patient's oral intake to optimize the patient's nutritional status for wound healing, and notify the physician when oral intake goal was not met.

Wound

Review of the Hospital (Transferred hospital) Discharge Instructions dated 2/4/19 revealed documentation of wound care as "Check incision right hip daily, cleanse with normal saline and cover with dry dressing...."

Review of the Pre-Screen Admission Update dated 2/4/19 revealed documentation of a "R hip incision."

Review of the Team Conference/Plan of Care Update dated 2/4/19 at 17:59 revealed documentation of the following Integumentary Goals: "Patient/Caregiver will demonstrate knowledge of wound care/dressing technique...wound(s) will be free of new infection or drainage...wound will show evidence of healing/tissue regeneration. "

Review of the IView Note(s) dated 2/4/19 revealed no documentation of the patient's wound(s) or a wound assessment.

Review of the Consults Note dated 2/5/19 revealed physician documentation of a "Right heel pressure ulcer."

Review of the Physician Orders dated 2/5/19 revealed a physician's order for a PRAFO (Pressure Relief Ankle Foot Orthosis) to the "RLE while in bed."

Further review of the Physician Orders 2/5/19 through 2/11/19 revealed no documentation of a physician's wound care order(s) for any wound.

Review of the IView note dated 2/5/19 revealed wound assessment documentation by EI # 4, Wound Care Coordinator, of the following wounds: "1 Right hip Surgical Incision", "2 Right Thigh Surgical Incision", "3 Right Knee Surgical Incision", and "A R heel Pressure Injury".

Further review of the IView note dated 2/5/19 by EI # 4 revealed no documentation of wound measurements for # 1, # 2, # 3, or A wounds or notification of the physician to obtain wound care orders.

Review of the wound photograph dated 2/5/19 revealed the R heel pressure injury as a "DTI (Deep Tissue Injury)."

Review of IView Note dated 2/6/19 at 7:32 AM revealed RN skin integrity documentation of "Intact, no abnormalities." There was no documentation of wounds # 1, # 2, # 3, or A.

Review of the Progress Notes dated 2/6/19 at 9:00 PM revealed the following LPN (Licensed Practical Nurse) documentation of wound # 1, "pt (patient) refuses for dressing to be changed to right hip. No drainage noted..." There was no documentation of the type of dressing that was on the right hip.

Review of the Progress Notes dated 2/7/19 at 4:00 AM revealed documentation of "noted bruised area on pt left upper arm bleeding. Cleaned with wound cleanser and pat dry. Applied Optifoam dressing to left upper arm bruised area..."

Further review of the Progress Notes dated 2/7/19 revealed no documentation the physician was notified of the new area to the left upper arm.

Review of the MR review no documentation of a wound care order or wound photograph for the left upper arm.

Review of the IView Note dated 2/7/19 at 8:00 AM revealed RN skin integrity documentation of "Intact, with abnormalities." There was no documentation of what the abnormalities where or of wounds # 1, # 2, # 3, or A.

Review of the IView Note dated 2/8/19 revealed RN skin integrity documentation of "Intact, no abnormalities" and wound "1 Right hip Surgical incision" dressing as "Dry, Intact." There was no documentation of the type of wound dressing that was on wound # 1 or wound assessments of wounds # 1, # 2, # 3, or A.

Review of the IView Notes dated 2/9/19 at 9:43 AM, 2/10/19 at 8:58 AM, 2/10/19 at 3:37 PM revealed RN skin integrity documentation of "Intact, no abnormalities."

Review of the IView Note dated 2/10/19 at 9:15 PM revealed RN skin integrity documentation of "Intact, with abnormalities" and a wound assessment of wound # 1. There was no documentation of wound measurements for wound # 1 or any documentation of wounds # 2, # 3, and A.

Review of the DC (discharge) Info (Information)/Summary dated 2/11/19 revealed skin integrity documentation of "Intact, no abnormalities". There was no documentation of wound information or wound care orders for wound(s) # 1, # 2, # 3, or A.

An interview was conducted on 4/3/19 at 10:41 AM with EI # 2, who confirmed the above findings.

4. PI # 4 was admitted to the facility on 3/21/19 with the diagnoses of Disuse Myopathy and Metabolic Encephalopathy.

Review of the Pre-Admission Information Note dated 3/21/19 revealed the following documentation, "patient has BLE (Bilateral Lower Extremity) leg wounds that are healing. Patient's leg wounds were positive for MRSA (Methicillin-Resistant Staphylococcus Aureus) on her/his prior hospitalization..."

Further review of the Pre-Admission Information Note dated 3/21/19 revealed the patient's prior hospitalization was from 3/6/19 through 3/12/19.

Review of the Physician Orders dated 3/21/19 revealed the following physician's orders, "Consult to wound team" and "Skin/Wound Assessment."

Review of the IView note dated 3/21/19 revealed the following RN documentation, the patient's skin integrity of "Intact, with abnormalities", "# 1 left leg other: scaling skin. Inc/Wnd (incision/wound) dressing other: none open to air", "# 2 right leg other: scaling skin. Inc/Wnd dressing other: open to air..."

Further review of the IView note(s) dated 3/21/19 revealed no documentation of the BLE leg wounds, assessment of the BLE leg wounds, or the wound team assessed the patient.

Review of the IView note dated 3/22/19 revealed a physician's order for "Consult to Wound Team."

Review of the IView note(s) 3/22/19 revealed no documentation of an assessment by the wound team.

Review of the IView note(s) for 3/22/19 and 3/23/19 revealed RN documentation of the patient's skin integrity as "Intact, no abnormalities." There was no documentation of wounds to the BLE.

Review of the IView note dated 3/24/19 revealed RN documentation of the patient's skin integrity as 'Intact, with abnormalities." There was no documentation of what the skin abnormalities were or of the wounds to the BLE.

Review of the Physician Orders dated 3/25/19 revealed a physician's order for the following wound care, "...Wound Cleanser, Dry, Daily, Clean BLE wounds, pat dry, and loosely cover with a gauze dressing..."

Review of the IView Note dated 3/25/19 revealed documentation of an assessment by the wound team, which was 4 days following the physician's order to consult the wound team. EI # 4 documented the assessment of the "A RLE (Right Lower Extremity) Venous Ulcer" as wound description/assessment "scabbing", wound drainage "None", signs of infection "None", and wound care documented as "Cleaned with Soap and Water" There was no documentation of wound measurements.

Further review of the IView Note dated 3/25/19 revealed documentation by EI # 4 of wound care to "# 1 left leg other: scaling skin" of "Cleaned with Soap and Water." There was no documentation of a LLE (left lower extremity) wound or an assessment of LLE wound.

EI # 4 failed to document wound measurements wound A, document assessment of a LLE wound, and provide wound care as ordered by the physician.

Review of the IView Note dated 3/26/19 revealed RN documentation of wound A as the following: wound description/assessment documented as "scabbing", wound drainage with signs of infection documented as "None", and wound care documented as "Cleaned with Wound Cleanser" There was no documentation of wound measurements.

Further review of the IView Note dated 3/26/19 revealed RN documentation of the "# 1 left leg other: scaling skin" with wound care of "Cleaned with Soap and Water." There was no documentation of a LLE wound or an assessment of LLE wound.

The RN failed to document wound measurements of wound A, document assessment of a LLE wound, and provide wound care as ordered by the physician on 3/26/19.

Review of the IView Note dated 3/26/19 at 6:53 AM revealed RN documentation of the patient's skin integrity as 'Intact, with abnormalities." There was no documentation of what the skin abnormalities were or of the wounds to the BLE.

Review of the Progress Note dated 3/26/19 at 12:22 PM revealed RN documentation of "Assessed BLE wounds. All VS (Venous Stasis) wounds have scabbed over...No exudate noted." There was no documentation of wound care being provided to the BLE wounds or wound measurements.

Review of the IView Note dated 3/27/19 revealed RN documentation of the wound description/assessment of wound A as "Closed/Resurfaced." There was no documentation of wound care to the RLE.

Further review of the IView Note dated 3/27/19 revealed RN documentation of the "# 1 left leg other: scaling skin" with wound care of "Cleaned with Soap and Water." There was no documentation of a LLE wound or an assessment of a LLE wound.

The RN failed to document an assessment of a LLE wound, and provide wound care as ordered by the physician on 3/27/19.

Review of the IView Note dated 3/28/19 revealed LPN (Licensed Practical Nurse) documentation of wound care to the wound A as "Cleansed with Wound Cleanser."

Further review of the IView Note dated 3/28/19 revealed no documentation of a LLE wound or and assessment of a LLE wound.

The LPN failed to document assessment of RLE Venous Stasis Ulcer, document a LLE wound, and provide wound care as ordered by the physician on 3/28/19.

Review of the IView Note(s) dated 3/29/19 at 12:12 PM and 3/29/19 at 8:00 PM revealed RN documentation of wound care to wound A as "Cleansed with Wound Cleanser."

Further review of the IView Note(s) dated 3/29/19 at 12:12 PM and 3/29/19 at 8:00 PM revealed no documentation of a LLE wound or an assessment of the LLE wound.

The RN failed to document assessment of the RLE Venous Stasis Ulcer, assessment of a LLE wound and provide wound care as ordered by the physician on 3/29/19.

Review of the IView Note(s) dated 3/30/19 at 8:58 AM and 3/30/19 at 11:43 AM revealed RN documentation of wound care to wound A as "Cleansed with Wound Cleanser."

Further review of the IView Note(s) dated 3/30/19 at 8:58 AM and 3/30/19 at 11:43 AM revealed RN documentation of wound care to the "B LLE Venous Ulcer" as "Cleansed with Wound Cleanser." There was no documentation of a wound assessment of wound B on 3/30/19.

Review of the IView Note dated 3/31/19 at 7:22 AM revealed RN documentation of the wound description/assessment of wound A as "Closed/Resurfaced" and wound care provided as "Cleansed with Wound Cleanser."

Further review of the IView Note dated 3/31/19 at 7:22 AM revealed RN documentation of the "# 1 left leg other: scaling skin" with wound care of "Cleaned with Soap and Water." There was no documentation of wound B or an assessment of wound B on 3/31/19.

Review of the IView Note dated 3/31/19 at 9:19 AM revealed RN documentation of wound(s) A and B with comment of "OTA (open to air)."

The RN failed to document an assessment of the BLE Venous Stasis Ulcers and document wound care per the physician's orders on 3/31/19.

Review of the Progress Notes dated 4/1/19 at 5:30 AM revealed LPN documentation of "cleansed BLE with wound cleanser and applied lightly gauze to BLE with kerlix wrap..."

Review of the IView Note dated 4/1/19 at 10:06 AM revealed RN documentation of wound care to wound A as "cleansed with Wound Cleanser" with a comment of "area dry scaley (scaly) skin only, no open areas, surrounding areas intact as well."

Further review of the IView Note dated 4/1/19 at 10:06 AM revealed no documentation of the wound B or an assessment of wound B.

Review of the IView Note dated 4/2/19 revealed EI # 4 documentation of wound A as "resolved"

Further review of the IView Note dated 4/2/19 revealed EI # 4 documented the presence of wound B however there was no documentation of a wound assessment or of wound care being provided to wound B.

The LPN failed to document an assessment of wounds A and B and provide wound care as ordered by the physician.

Review of the MR revealed no wound measurements for wounds A or B.

An interview was conducted on 4/4/19 at 5:34 PM with EI # 2, who confirmed the above findings.

5. PI # 5 was admitted to the facility on 3/20/19 with the diagnoses of S/P (status post) I&D (Incision and Drainage) Bilateral Elbow Septic Arthralgia and Sepsis.

Review of the Interactive View (IView) Print Request notes revealed the following dates the Braden Score was documented as 18 or below:

On 3/20/19, Braden Score 18
On 3/21/19, Braden Score 17
On 3/22/19, Braden Score 18
On 3/24/19, Braden Score 18
On 3/25/19, Braden Score 17
On 3/26/19, Braden Score 17
On 3/27/19, Braden Score 17
On 3/29/19, Braden Score 16
On 3/30/19, Braden Score 16
On 3/31/19, Braden Score 18
On 4/1/19, Braden Score 18
On 4/2/19, Braden Score 18
On 4/3/19, Braden Score 17 at 8:55 AM and 18 at 9:41 PM

Review of the Physician Orders dated 3/20/19 revealed a physician's order for "Skin Care Protocol" with comment of "order entered secondary to documenting a Braden Score less than 18."

Review of the progress note dated 3/20/19 revealed the following nursing documentation, "...noted redness to ...buttocks..."

Review of the IView notes dated 3/20/19 and 3/21/19 revealed patient was able to turn self.

Review of the MR from 3/22/19 through 4/2/19 revealed no documentation of the patient's position or if patient was compliant with repositioning self to avoid skin breakdown.

Dietary

Review of the Intake and Output report dated 3/20/19 through 4/2/19 revealed an oral intake of "100" ml (milliters) documented for 3/20/19.

Further review of the Intake and Output report dated 3/20/19 through 4/2/19 revealed no documentation of an oral intake for 3/21/19 through 4/2/19.

Review of the IView notes dated 3/26/19 through 4/2/19 revealed no documentation of the amount of breakfast, lunch, or dinner that patient consumed.

Wound

Review of the physician's order dated 3/28/19 revealed a physician's phone order for "q3day (every 3 days) buttock, Clean skin tear with wound cleanser, pat dry and apply Optifoam dressing..."

Review of the IView note dated 3/28/19 revealed EI # 4, documented the right buttock wound as 1.8 cm in length and 1 cm in width. T

Based on observations, review of CDC guidelines, facility policy and procedures, and interviews, it was determined the staff failed to perform hand hygiene per policy.

This affected Patient Identifier (PI) # 5 and unsampled patient # 1, and had the potential to negatively affect all patients served by the facility.

Findings include:

CDC Guidelines to Hand Hygiene Volume 51, Published 2002

Recommendations

"1. Indications for handwashing and hand antisepsis

...G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled.

H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care.

I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.

J. Decontaminate hands after removing gloves ..."

Policy: Hand Hygiene
Policy Number: 170
Date: 1/25/18

Purpose: To decrease the risk of transmission of infection by appropriate hand hygiene...

Policy: Every employee will use proper hand hygiene and hand washing techniques while within the facility

Indications for Handwashing and Hand Antisepsis
...Wash hand after removing gloves

Other aspects of hand hygiene
...4. Change gloves and perform hand hygiene during patient care if moving from a contaminated body site to a clean body site.

Policy: Disinfection and Sterilization
Policy Number: 140
Date: 1/25/18

Purpose: To provide supplies and equipment that are adequately cleaned, disinfected or sterilized...

Policy:
III. Low Level Disinfection Policy (cleaning/disinfection of common equipment)
...All equipment that touches patients should be disinfected in between patient contacts...

1. PI # 5 was admitted to the facility on 3/20/19 with the diagnoses of S/P (status post) I&D (Incision and Drainage) Bilateral Elbow Septic Arthralgia and Sepsis.

Review of the physician's order dated 3/28/19 revealed a physician's order for "...buttock, Clean skin tear with wound cleanser, pat dry and apply Optifoam dressing..."

An observation was conducted on 4/2/19 at 1:04 PM to observe wound care provided to PI # 5 Right Buttock "skin tear" by Employee Identifier (EI) # 4, Registered Nurse (RN) Wound Care Coordinator.

EI # 4 gathered and placed the wound care supplies, wound measurement ruler, and camera on the patient's bed linen without placing a barrier.

EI # 4 cleaned the right buttock wound with two chlorhexadine swabsticks, and cleaned the left buttock area (directly across from right buttock wound) with the same two chlorhexadine swabsticks, then returned to right buttock wound and cleaned again with the same two chlorhexadine swabsticks thereby cross contaminating the right buttock wound.

The used chlorhexadine swabsticks were placed on top of the clean wound care supplies on the patient's bed linen.

EI # 4 used the wound measurement ruler that had been placed on the bed linen to measure the wound, took pictures of the wound and then preceded to apply the Optifoam dressing to the wound while wearing the same gloves.

EI # 4 failed to change gloves and perform hand hygiene after removing soiled dressings and failed to perform wound care in a manner to prevent cross contamination of wound.

An interview was conducted on 4/3/19 at 4:17 PM with EI # 3, Quality Assurance Risk Manager, and EI # 6, Nurse Educator/Infection Prevention, who confirmed EI # 4 failed to follow the facility policy for hand hygiene.

2. An observation was conducted on 4/2/19 at 1:11 PM to observe wound care provided to unsampled patient # 1's bilateral lower extremities (BLE) venous status ulcers by Employee Identifier (EI) # 4, Registered Nurse (RN) Wound Care Coordinator.

EI # 4 gathered the wound care supplies and placed them on the patient's bedside table next to patient's personal items without first cleaning the bedside table or placing a barrier.

EI # 4 removed the wound drainage soaked sock and dressing from the patient's left lower leg/foot and placed wound cleanser moistened gauze on top of the left leg ulcers without first changing gloves and performing hand hygiene.

EI # 4 removed gloves and donned clean gloves without performing hand hygiene.

EI # 4 placed wound cleanser moistened gauze on top of the right leg ulcers then removed gauze from left leg ulcers without removing gloves or performing hand hygiene between wounds.

EI # 4 removed gloves and donned clean gloves without performing hand hygiene.

EI # 4 completed wound care to the left leg, removed gloves, and donned clean gloves without performing hand hygiene.

EI # 4 removed wound cleanser moistened gauze placed previously from the right leg and completed the wound care.

EI # 4 removed trash, removed gloves, and obtained pen from the right uniform pocket, wrote on both wound bandages, and replaced pen in the right uniform pocket without hand hygiene or cleaning pen prior to use or after use.

An interview was conducted on 4/3/19 at 4:17 PM with EI # 3 and EI # 6, who confirmed EI # 4 did not follow standards of practice.