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Based on observations, document review and interview, it was determined the facility failed to provided a sanitary environment to avoid sources and transmission of infections for patients and staff.

Please see Tags 392, 749 and 756 for more detailed information related to this condition.

Based on observation, documentation and interview, the facility staff failed to ensure the physician's orders for wound care and nutrition were followed for six (6) of seven (7) patients, Patients #7, #8, #5, #10, #11 and #12.

The findings include:

1. On 6/4/18 at approximately 2:04 P.M. wound care for Patient #7 was observed. Patient #7 had an abdominal wound and a sacral wound. When the dressing was removed there was no drainage bag in place. When the dressing was reapplied no drainage bag was applied.

A physician's order was written on 5/23/18 at 3:45 P.M. stating, "Wound care to place drainage bag on questionable fistula now- bag not to be removed until 5/24/18 evening by wound care only."
A review of the documentation by wound care in the medical record indicated the bag was not removed until 5/25/18 at 11:13 A.M. or the physician contacted until 5/25/18.

A physician's order was written on 5/29/18 at 6:00 A.M. stating, "Drainage bag to be placed over Rt (right) ischium for collection of fluid today 5/29 - DO NOT remove, take off, suspend drainage, etc until fluid collected and sent for urine cr. (creatine)".

An interview with Staff Member #16 was conducted on 6/5/18 at 12:00 Noon. Staff Member #16 stated, "We are still trying to collect the urine sample. They (nursing staff) have not kept the drainage bag attached."

Staff Member #2 was informed of the above information on 6/5/18 and stated, "The urine may have been collected that is why no bag was in place or placed. I will check to see if the urine was sent to the lab." No information regarding a urine sample or lab report was provided.

2. Patient #8 was admitted on 1/7/15 with the diagnoses of Chronic Respiratory Failure, Pressure Ulcer Stage IV Sacrum and Anoxic Brain Damage; later diagnosed with MRSA. Staff Member #16 was interviewed on 6/5/18 regarding Patient #8's wound care and nutritional status. Staff Member #16 stated, "(Name of Patient #8) came in with one pressure ulcer and acquired three (3) more while here. We healed one but it has not been easy. His/Her tube feeding was changed to Glucerna to increase the amount of protein he/she was receiving to promote healing. But there are times when it was documented he/she was receiving Jevity. His/Her pre-albumin was down to 12 or 13 and it should be 22."

Staff Member #15 was interviewed on 6/5/18 at approximately 12:50 P.M. and stated, "(Name of Patient #8) was changed in late March early April from Jevity to Glucerna for his/her tube feedings for the increased protein to help with wound healing."

A review of Patient #8 medical record revealed Patient #8 received Jevity 1.5 instead of the ordered Glucerna 1.5 on the following:
5/8/18 at 12:20 A.M.,
5/12/18 at 12:20 A.M.,
5/14/18 at 12:04 A.M.,
5/17/18 at 12:02 A.M.,
5/18/18 at 12:01 A.M.,
5/22/18 at 12:02 A.M.,
5/26/18 at 12:04 A.M.,
5/28/18 at 12:03 A.M.,
6/3/18 at 12:00 Midnight.

All physician progress notes from 5/2/18 to 6/4/18 address Dietary as "Continue Glucerna 1.5".

Progress note documented by Dietitian dated 5/29/18 at 12:15 A.M. states, "RD Follow-up: 5/23: PreAlbumin 12. Clarifying current order for patient: Glucerna 1.5 (high protein formula) @ (at) 35 ml/hr (milliliters per hour) X (times) 24 hours continuous + H20 (water) flush @55 ml/hr X 24 hour continuous + SF ProStat 30 cc (centimeters) QID (four times a day) to provide 1660 kcal (calories) and 130 grams PROTEIN per day. Jevity 1.5 documented in notes this week which may contribute to lowered protein intake. Dietary to ensure Glucerna 1.5 product is consistently delivered and available to unit for updated orders from 4/3/18. Additional routine RD assessments located in Clinical Documentation/Assessment. Will follow for changes and discuss adjustments in w/team (wound team) prn (whenever necessary)."

3. Patient #5 was admitted on 2/22/18 with the diagnoses of Chronic Respiratory Failure, anoxic encephalopathy and End Stage Renal Disease. Patient #5 was discharged to the acute care hospital on 5/9/18 with an infected right femoral tunneled dialysis catheter and septic shock due to vancomycin-resistant Enterococcus (VRE) and carboplatin resistant Escherichia coli (E. coli) as well as Morganella from the sacral wound and C-difficile colitis. Patient #5 was transferred back to this facility on 5/22/18.

Morganella morganii is a gram-negative rod commonly found in the environment and in the intestinal tracts of humans, mammals, and reptiles as normal flora. Despite its wide distribution, it is an uncommon cause of community-acquired infection and is most often encountered in postoperative and other nosocomial settings. Oct 5, 2015 Morganella Infections: Background, Pathophysiology, Epidemiology https://emedicine.medscape.com/article/222443-overview.

Staff Member #18 was asked about wound care for Patient #5 not being done. Staff Member #5 stated, "On 5/28/18 during a wound treatment team meeting the wound doctor and nurse brought up they had discovered a dressing not done the previous night for (Name of Patient #5). I looked to see who was assigned to the patient and talked to the charge nurse who signed the dressing change had been done. The charge nurse signed they did the dressing change and when I spoke to them said they did the dressing change. The dressing the doctor removed had the same date and time for when the dressing change was done by the previous nurse. I re-educated the charge nurse on how to document dressing changes. I discussed with (Name of Chief Nursing Officer and Director of Nursing) the results of my meeting with the charge nurse. Two week prior to this the dressing changes where not performed as ordered by the physician."


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4. On June 6, 2018 at 10:00 a.m. a medical record review revealed the following:
Patient # 10 - Physician orders read "sacral wound: cleanse with puracyn plus, apply santyl and drawtek bid and PRN cover with optiform BID and PRN". A review of the Treatment Administration Record (TAR) revealed the wound care was not signed off as performed on March 4, 5, 9 and 12 on the 7P - A shift.

5. Patient # 11 - Physician orders read "sacral wound: cleanse with puracyn plus. apply /pack aliginate BID, cover with optifoam BID". A review of the TAR revealed the wound care was not signed off as performed on March 4 and 11 on the 7P - A shift.

6. Patient # 12 - Physician orders read "sacral wound: clean with puracyn plus apply santyl/alginate BID cover with allevyn BID". A review of the TAR revealed the wound care was not signed off as performed on March 5 7P - A shift.

A review of the Wound Care Meeting Notes revealed Staff Member # 16 voiced concerns about wound care not being performed as ordered on March 6 and 27, 2018.

Based on observations, document review and interview, it was determined that the facility failed to provide a sanitary environment to avoid sources and transmission of infections during random observations of five (5) of five(5) Staff Members (Staff members #5, #6, #7, #11, and #13).

The findings include:

1. During the initial facility tour on June 4, 2018 the following was observed:

At 1:20 p.m. Staff Member # 7 was observed during daily room cleaning for Patient # 2. Patient # 2 has precaution sign on door with stop sign and writing "Please see the nurse before entering room", and pictures of handwashing, gloves, gown and mask. Staff Member # 7 was wearing mask, gloves and gown while wiping surfaces in Patient # 2's room. Staff Member # 7 returned to the housekeeping cart that was positioned in the doorway of Patient # 2's room and opened the cart door and removed a bottle of cleaner with dirty gloves on. Staff Member # 7 entered Patient # 2's room using the bottle of cleaner to clean with. Staff Member # 7 returned the bottle of cleaner to the housekeeping cart. Staff Member # 7 never removed dirty gloves or sanitized the bottle of cleaner before returning it to the housekeeping cart. Staff Member # 7 swept the floor with the broom and dust pan from the housekeeping cart. The dirt from the dust pan was placed in the trash container on the housekeeping cart and the broom and dust pan were placed in the trash container also. Staff Member # 7 mopped the floor with a mop and water from the housekeeping cart. The dirty mop was placed back in the bucket of water that was on the housekeeping cart. Staff Member # 7 removed mask, gown and gloves and placed in trash container on the housekeeping cart and performed hand hygiene.

Staff Member # 7 moved the housekeeping cart to the doorway of Patient # 5's room. Patient # 5 has precaution sign on door with stop sign and writing "Please see the nurse before entering room", and pictures of handwashing, gloves, gown and mask. Staff Member # 7 donned mask, gown and gloves before entering Patient # 5's room. Staff Member # 7 removed bottle of cleaner from the housekeeping cart to clean in the room of Patient # 5 and return the cleaner to the housekeeping cart. Staff Member # 7 used the same broom and dust pan from trash container on the housekeeping cart that was also used in Patient # 2's room. Staff Member # 7 used the same mop and water from the housekeeping cart that was also used in Patient # 2's room.

At 1:30 p.m. Staff Member # 6, a licensed practical nurse (LPN), was observed entering Patient # 2's room with the vital sign machine while Staff Member # 7 was cleaning in the room. Staff Member # 6 pushed passed the housekeeping cart and walked to the patient's bedside with the vital sign machine. Staff Member # 6 then came back to the doorway and donned mask, gown and gloves. Staff Member # 6 did not perform hand hygiene upon entering the room. Staff Member # 6 place the blood pressure cuff from the vital machine on Patient # 2's arm. Staff Member # 6 removed mask, gown and gloves before leaving the room. Staff Member # 7 pushed the vital machine with dirty gloved hand so that the floor could be mopped. Staff Member # 6 touched the vital machine with ungloved hand after Staff Member # 7 and took the vital sign machine back to the nursing station. Staff Member # 6 failed to clean the vital sign machine or the blood pressure cuff after use.

At 1:40 p.m. Staff Member # 6 was observed during medication administration for Patient # 6. Patient # 6 has precaution sign on door with stop sign and writing "Please see the nurse before entering room", and pictures of handwashing, gloves, gown and mask. Staff Member # 6 donned mask, gown and gloves and entered the room. Staff Member # 6 returned the medication cart and removed gloves but did not perform hand hygiene. Staff Member # 6 prepared medications for administration and administer medications to the patient without gloves.

At 1:50 p.m. Staff Member # 5, a certified nursing assistant (CNA), was observed entering the room for Patient's # 3 and # 4. Patient's # 3 and # 4 rooms do not have a precaution sign. Staff Member # 5 obtained the vital sign machine from the nursing station and touched it with ungloved hands. Staff Member # 5 entered the room without cleaning the vital sign machine or blood pressure cuff and performed no hand hygiene. Staff Member # 5 used the same vital sign machine and blood pressure cuff on both Patient # 3 and # 4 with cleaning.

An interview with Staff Member # 2 on June 4, 2018 at 1:35 p.m. revealed that any equipment that enters a room with precautions should be wiped with purple wipes when leaving the room. This would include the vital sign machine and blood pressure cuff according to Staff Member # 2.

The policy titled "Standard Cleaning Method, Patient Rooms" provided by Staff Member # 2 on June 5, 2018 at 9:00 a.m. reads, in part: "Isolation resident rooms - isolation rooms will be cleaned daily following the same procedures for cleaning resident rooms but use the following precautions. Put on PPE (personal protective equipment) before entering room. Consult with nursing to determine what clothing is necessary. Follow the signage for PPE usage on door. Wash hands. Empty all trash cans and liners into red plastic liner. Replace with red or white bio hazard plastic liners. Change mop and solution of every isolation resident's rooms or area. Damp mop floors, empty mop bucket and refill with fresh disinfectant solution of all isolation rooms. Remove soiled mop, place in red liner and place clean mop head on mop handle of all isolation rooms."

The policy titled "Administration of medications in rooms with precautions" provided by Staff Member # 2 on June 5, 2018 at 9:00 a.m. reads, in part: "The nurse is to clean hands prior to preparing the medications. Before going into the room, the nurse should look at the isolation sign to see which PPEs are needed. The nurse is to foam in then put on all necessary PPE. Isolation rooms should have single patient use stethoscopes, blood pressure cuffs and thermometers. Any shared equipment must be cleaned according to policy. Wash hands and use alcohol foam prior to leaving the room."

The policy titled "Vital signs for patients on precautions" provided by Staff Member # 2 on June 5, 2018 at 9:00 a.m. reads, in part: "Each patient requiring precautions should have a blood pressure cuff, stethoscope and thermometer at the bedside. These items are to be used when taking vital signs. Foam in and put on PPE. Wipe vital sign machine, including O2 monitor with a sanitizing wipe before using on the patient. Once vital signs are completed, remove PPE and wash hands. Put on a clean pair of gloves and thoroughly wipe the machine using sanitizing wipes before taking from room or using on another patient. Remove machine from room after cleaning."


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2. On 6/4/18 at approximately 2:04 P.M. wound care for Patient #7 was observed. Patient #7 had an abdominal wound (dehisced where a previous peg tube for feeding was inserted) and a stage IV sacral pressure wound. Patient #1 is on contact precautions for MRSA (Methicillin-resistant Staphylococcus aureus).

Staff Member #11 was observed removing the soiled dressing from the sacral wound, removing gloves and replacing gloves without performing hand hygiene. Staff Member #11 cleaned the wound, obtained a culture and placed the culture in a plastic bag. Staff Member #11 told Staff Member #13 they might want to put on a glove to take the culture specimen. Staff Member #13 placed one glove on and took the culture specimen. Staff Member #11 with same gloved hand that passed the culture specimen to Staff Member #13 placed a pen in their scrub pocket under their PPE (personal protective equipment). Staff Member #13 handed Staff Member #11 four (4) dressings with the time 7A - 7P on each of them but no initials or dates. Staff Member #11 proceeded to place the dressing over the sacral wound. After placing the dressings over the sacral wound, Staff Member #11 removed gloves and put on new gloves and proceed to clean Patient #7's abdominal wound. No hand hygiene was ever performed in the process of cleaning and dressing the two wounds.

Staff Member #11's finger nails were approximately one-half (1/2) inch beyond the end of their finger and appeared to be artificial.

Staff Member #16 was interviewed on 6/5/18 at approximately 12:00 Noon regarding the cleaning of wounds. Staff Member #16 stated, "All wounds are dirty, some are contaminated. My preference in treating and cleaning is to go from the most clean to the least clean. They should have preformed the cleaning of the abdominal wound first."

Staff Member #9 was interviewed on 6/6/18 at approximately 12:35 P.M. and stated, "It really shouldn't matter which wound is cleaned first if the person is changing their gloves and performing hand hygiene as they should. I personally would go from cleanest to dirtiest, first the surgical wound then the sacral wound. After removing the dressing, the gloves should be discarded, hand hygiene performed, clean gloves, clean the wound, discard gloves hand hygiene, new gloves then apply treatment, discard gloves, perform hand hygiene, new gloves then apply the clean dressing. Nails should be short enough that you don't poke a hole through your gloves."

Staff Member #17 was interviewed on 6/6/18 at approximately 12:15 P.M. Staff Member #17 stated, "I am the person who supervise the wound care nurses. (Name of wound care nurse) was an agency nurse here prior to May 6th. I spoke to her about the length of her nails back in April. During orientation I spoke with her about the length of her nails."

Staff Member #19 was interviewed on 6/6/18 at 11:20 A.M. Staff Member #19 reviewed a document (Section 4: Employee Handbook; pages 1-4) provided by Staff Member #2 and identified the document as a portion of the "Employee Handbook". Staff Member #19 reviewed Page 3 Section D and stated, "as a practice artificial nails are not acceptable in a healthcare setting if you are giving direct patient care. I spoke the wound nurses' supervisor informing her the wound nurses' nails were not acceptable in length."

3. On 6/4/18 at approximately 1:30 P.M. Staff Member #13 was observed administering medication to Patient #8. Patient #8 is on contact precautions for MRSA. Staff Member #13 was observed removing a stethoscope from an IV pole which had Patient #8's tube feeding and a bag with a large irrigation syringe in it used to administer water flushes and medications through the tube feeding tube. Staff Member #13 placed the stethoscope around their neck, removed it, and listened to Patient #8 abdomen and placed the stethoscope back on the IV pole. Staff Member #13 never cleaned the stethoscope prior to placing around their neck or back on the IV pole. Staff Member #13 stated, "I should have cleaned it before I put it around my neck or not put it around my neck."


CDC (Centers for Disease Control) web site states: MRSA is methicillin-resistant Staphylococcus aureus, a type of staph bacteria that is resistant to many antibiotics. In a healthcare setting, such as a hospital or nursing home, MRSA can cause severe problems such as bloodstream infections, pneumonia and surgical site infections. If not treated quickly, MRSA infections can cause sepsis and death.

In a healthcare setting MRSA is usually spread by direct contact with an infected wound or from contaminated hands, usually those of healthcare providers. Also, people who carry MRSA but do not have signs of infection can spread the bacteria to others.

CDC web site states: Use Contact Precautions (Contact isolation precautions. Contact isolation precautions-used for infections, diseases, or germs that are spread by touching the patient or items in the room (examples: MRSA, VRE, diarrheal illnesses, open wounds, RSV). Healthcare workers should: Wear a gown and gloves while in the patient's room. patients with known or suspected infections that represent an increased risk for contact transmission.)
· Use disposable or dedicated patient-care equipment (e.g., blood pressure cuffs). If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient.
· Prioritize cleaning and disinfection of the rooms of patients on contact precautions ensuring rooms are frequently cleaned and disinfected (e.g., at least daily or prior to use by another patient if outpatient setting) focusing on frequently-touched surfaces and equipment in the immediate vicinity of the patient.

Based on interview, observation and document review, the facility staff failed to ensure that the hospital-wide quality assessment and performance improvement (QAPI) program and training programs address problems identified by the infection control officer or officers; and was responsible for the implementation of successful corrective action plans in affected problem areas.

The findings include:

The wound nurse was observed was observed on 6/4/18 performing wound care. No hand hygiene was ever performed in the process of cleaning and dressing the two wounds.

Staff Member #11's finger nails were approximately one-half (1/2) inch beyond the end of their finger and appeared to be artificial.

Staff Member #16 was interviewed on 6/5/18 at approximately 12:00 Noon regarding the cleaning of wounds. Staff Member #16 stated, "All wounds are dirty, some are contaminated. My preference in treating and cleaning is to go from the most clean to the least clean. They should have preformed the cleaning of the abdominal wound first."

Staff Member #9 was interviewed on 6/6/18 at approximately 12:35 P.M. and stated, "It really shouldn't matter which wound is cleaned first if the person is changing their gloves and performing hand hygiene as they should. I personally would go from cleanest to dirtiest, first the surgical wound then the sacral wound. After removing the dressing the gloves should be discarded, hand hygiene performed, clean gloves, clean the wound, discard gloves hand hygiene, new gloves then apply treatment, discard gloves, perform hand hygiene, new gloves then apply the clean dressing.
Nails should be short enough that you don't poke a hole through your gloves."

Staff Member #17 was interviewed on 6/6/18 at approximately 12:15 P.M. Staff Member #17 stated, "I am the person who supervise the wound care nurses. (Name of wound care nurse) was an agency nurse here prior to May 6th. I spoke to her about the length of her nails back in April before being hired. During orientation I spoke with her about the length of her nails again."

Staff Member #18 was asked to identify the members of the wound care team and stated, "The wound doctor, myself, the wound nurse, the Director of Nursing, and Nurse Manager for wound care. and (Name of the Chief Nursing Officer). Most of the time they are all present when we discuss wound care."

Staff Member who preferred to remain anonymous stated, "Only the CEO has the authority to hire or fire someone for not following the protocols we have in place."

Staff Member #19 was interviewed on 6/6/18 at 11:20 A.M. Staff Member #19 reviewed a document (Section 4: Employee Handbook; pages 1-4) provided by Staff Member #2 and identified the document as a portion of the "Employee Handbook". Staff Member #19 reviewed Page 3 Section D and stated, "as a practice artificial nails are not acceptable in a healthcare setting if you are giving direct patient care. I spoke the wound nurses' supervisor informing her the wound nurses' nails were not acceptable in length."

Staff Member #8 stated, "The issues are presented in Quality but then pushed back to the respective departments to address and report on."


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On June 6, 2018 at 10:00 a.m. a medical record review revealed the following:
Patient # 10 - Physician orders read "sacral wound: cleanse with puracyn plus, apply santyl and drawtek bid and PRN cover with optiform BID and PRN". A review of the Treatment Administration Record (TAR) revealed the wound care was not signed off as performed on March 4, 5, 9 and 12 on the 7P - A shift.

Patient # 11 - Physician orders read "sacral wound: cleanse with puracyn plus. apply /pack aliginate BID, cover with optifoam BID". A review of the TAR revealed the wound care was not signed off as performed on March 4 and 11 on the 7P - A shift.

Patient # 12 - Physician orders read "sacral wound: clean with puracyn plus apply santyl/alginate BID cover with allevyn BID". A review of the TAR revealed the wound care was not signed off as performed on March 5 7P - A shift.



An interview with Staff Members # 8 and # 9 on June 6, 2018 at approximately 9:15 a.m. revealed that the infection control program tracks and monitors all infections and wounds in the facility. All of the information from the infection control program is presented at the Quality meetings. Any issues that arise are usually sent back the respective department to address with staff and educate and/or correct as required.

A review of the Wound Care Meeting Notes revealed Staff Member # 16 voiced concerns about wound care not being performed as ordered on March 6 and 27, 2018.