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Based on policy review, medical record review, and staff interview, the facility failed to ensure wound measurements were documented weekly. This affected one, Patient #1, of 10 medical records reviewed. The hospital census was 217.

Findings include:

Hospital policy #662 Wound Care: Management and Treatment, dated 04/18/13 documented incision and wound assessments would include weekly measurements including length, width, and depth.

On 12/16/15, the medical record for Patient #1 was reviewed including wound treatment notes from 10/29/15 though 12/15/15. The wound treatment notes documented an unstageable pressure ulcer of the coccyx found and identified on 10/29/15.

The wound was first measured on 11/10/15, 12 days after the wound was identified. The coccyx wound was next measured on 11/19/15 (nine days later), on 12/04/15 (15 days later), on 12/11/15 (7 days later), and 12/15/15 (4 days later).

On 12/16/15 at 11:00 AM, the Wound Team Manager, Staff L, confirmed Patient #1's wound measurements were not documented weekly per hospital policy.

Based on policy review, observation, and staff interview, the facility failed to ensure infection control measures were implemented per hospital policy including hand hygiene, sterile glove use, and maintaining a sanitary environment . This affected three, Patient #1, #2, and #3, of three infection control observations made. The hospital census was 217.

Findings include:

Hospital policy entitled; Hand Hygiene Policy, dated 06/08/15 documented hand hygiene should be conducted "before and after using gloves" and to "decontaminate hands before donning sterile gloves".

Hospital policy entitled; Infectious Waste Management Plan, revised on 10/20/15 documented infectious wastes including liquids such as blood products, body fluids, and excreta, and containers filled with body fluids such as suction canisters, should be treated (removed) as soon as possible after generation including pouring liquid infectious wastes into a sanitary sewer system.

1. On 12/14/15 at 2:00 PM, an observation of Patient #2's incisional wound-vac dressing change was made. Wound team nurse, Staff N, was observed removing the dressing with clean gloves. The gloves were removed and new clean gloves were put on without using a hand jell or soap and water. Staff N continued the procedure with clean gloves and removed the wound vac foam from the incision site and cleaned and flushed the site with normal saline. Staff N then opened a sterile glove package and placed the sterile gloves over the contaminated clean gloves just used to clean the incision site. Staff N, with sterile gloves then physically checked the incision site for tunneling. Staff N then removed the gloves and washed with soap and water before applying new sterile gloves.

On 12/14/15 at 2:30 PM, the Regulatory Compliance Officer, Staff J, who observed the dressing change, confirmed Staff N failed to clean hands between clean glove use and failed to remove contaminated gloves and wash hands before putting sterile gloves over contaminated gloves.

2. On 12/15/15 at 8:30 AM, an observation of Patient #1's unstageable coccyx pressure ulcer dressing change was made. There were no infection control issues or concerns noted with the dressing change, however, three suction canisters were observed in the room. Two of the canisters were full and the third was more than half full. Patient #1's family stated the canisters were full of bile and vomit that had been suctioned two days prior to the observation. The family stated tube feedings had been stopped two days ago due to vomiting, and the canisters had been full and not replaced since then.

On 12/15/15 at 11:30 AM, the Chief Nursing Officer, Staff C, who observed the full suction canisters, confirmed the canisters were full and had not been removed according to the family, for two days.

3. On 12/16/15 at 8:35 AM, an observation of Patient #3's Stage IV Coccyx pressure ulcer was made. The floor nurse, Staff O, was observed cleaning the site with sterile gloves which became contaminated. Staff O then proceeded to apply Santyl medication to the wound site with the same contaminated sterile gloves but was stopped before touching the wound. The nurse was reminded by the Regulatory Compliance Officer, Staff J, the sterile gloves were now contaminated. Staff O proceeded to remove the gloves, clean hands with soap and water, and put on new sterile gloves.

On 12/16/15 at 9:05 AM, the Regulatory Compliance Officer, Staff J, who observed the dressing change, confirmed Staff O failed to change contaminated sterile gloves without prompting from administration.