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Based on observations, record reviews, interviews, and the hospital's policies and procedures, the hospital's nursing staff failed to follow physician orders, and failed to use acceptable principles of infection control in the provision of wound care, and failed to ensure the provision of wound care via physician orders for patients admitted to the hospital during the weekend period.

The findings are:

Cross Reference to A 392: The hospital failed to ensure its staff documented the patient's wound care was completed as ordered for 4 of 10 patient charts reviewed (Patient 1, 3, 5, and 7); failed to document the date the patient's dressing was changed on the patient's dressing per hospital policy for 4 of 4 patients requiring wound care whose dressing was observed (Patient 11,12, 13, and 15), treatment orders had not been initiated on admission for a pressure ulcer and surgical abdominal wound for 2 of 10 patient charts reviewed for surgical wound care and services (Patient 8) and for pressure ulcers for Patient 5; 1 of 1 patient did not receive Prostat as ordered for 2 doses (Patient 5); Intake and Output orders had not been followed for 1 of 1 patient with orders for output measurement (Patient 1), 1 of 1 patient with physician orders for "out of bed" dated 1/13/2019 had nursing documentation that showed bed rest for five days after the physician order was written, and 1 of 1 patient interviewed who reported no bath since admission had no nursing documentation of a bath since admission(Patient 5). The hospital failed to ensure 3 of 3 Registered Nurses (RN 4, 5 and 6), and 1 of 1 Certified Nursing Assistant (CNA 1) followed acceptable principles for infection control to prevent the potential cross transmission of infectious agents by failure to change gloves and perform hand hygiene when indicated after touching "contaminated" surfaces or during the provision of wound care.

Based on observations and interview, the Hospital failed to ensure patient information was maintained in a secure manner.

The findings are:

On 1/14/19 at 4:27 p.m., observations in the "B wing" of the hospital, at room 2102, revealed a clipboard with patient information, titled "RT(Respiratory Therapy)Pt(Patient) List", propped up on the rail on the wall in the hallway. The finding was verified with the Chief Clinical Officer (CCO) on 1/14/19 at 4:27 PM.

Based on observations of care, record reviews, and interviews, the hopsital failed to ensure nursing followed physician orders, failed to coordinate new admission patient's wound care with the physician, and failed to follow accepted principles of infection control in the provison of wound care for those patients in need of wound care.

The findings are:

Cross Reference to A392: Based on record reviews, interviews, and a review of the hospital's policy, entitled, "Utilization of the BWAT (Bates Jensen Wound Assessment Tool) to Measure Wound Healing", revised 3/2018, the hospital failed to ensure its staff documented the patient's wound care was completed as ordered for 4 of 10 patient charts reviewed (Patient 1, 3, 5, and 7); failed to document the date the patient's dressing was changed on the patient's dressing per hospital policy for 4 of 4 patients requiring wound care whose dressing was observed (Patient 11,12, 13, and 15), treatment orders had not been initiated on admission for a pressure ulcer and surgical abdominal wound for 2 of 10 patient charts reviewed for surgical wound care and services (Patient 8) and for pressure ulcers for Patient 5; 1 of 1 patient did not receive Prostat as ordered for 2 doses (Patient 5); Intake and Output orders had not been followed for 1 of 1 patient with orders for output measurement (Patient 1), 1 of 1 patient with physician orders for "out of bed" dated 1/13/2019 had nursing documentation that showed bed rest for five days after the physician order was written, and 1 of 1 patient interviewed who reported no bath since admission had no nursing documentation of a bath since admission(Patient 5). The hospital failed to ensure 3 of 3 Registered Nurses (RN 4, 5 and 6), and 1 of 1 Certified Nursing Assistant (CNA 1) followed acceptable principles for infection control to prevent the potential cross transmission of infectious agents by failure to change gloves and perform hand hygiene when indicated after touching "dirty" surfaces or during the provision of wound care.

Based on record reviews, interviews, and review of hospital policies, the Hospital failed to ensure 3 of 5 patient records reviewed (Patient 2, 9, and 10) had updated written physician orders for restraints.

The findings are:

On 1/15/19 at 11:20 a.m., observations in room Patient 2's room revealed the patient had bilateral soft wrist restraints. Review of the patient's chart revealed a "Restraint Order and Flowsheet" dated 12/29/2018 had been initiated by nursing, but there was no physician signature on the order. The finding was verified with the Director of Nursing (DON) on 1/15/19 at 12:33 PM.

On 1/15/19 at 11:45 a.m., observations in Patient 9's room revealed the patient had bilateral soft wrist restraints. Review of the patient's chart revealed a "Restraint Order and Flowsheet" dated 12/17/18 had been initiated by nursing staff, but the order was not signed by the physician until 12/28/18. On 12/22/18, a "Restraint Order and Flowsheet" had been initiated by nursing, but there was no physician signature on the order. Documentation revealed the patient was in bilateral wrist restraints on 12/30/2018, but there was no "Restraint and Order Flowsheet" in the patient's chart. In an interview with the Director Of Nursing (DON), the DON verified the findings on 1/15/19 at 12:35 PM. The DON stated, "The doctors must sign the orders the same day they are initiated, and these orders must be renewed every twenty-four hours."

On 1/15/19 at 11:55 a.m., observations in Patient 10's room revealed the patient had bilateral soft wrist restraints attached to prevent the patient from pulling at necessary tubes and dressings. Further review of the patient's chart revealed there was no "Restraint and Order Flowsheet" for the bilateral wrist restraints dated 12/31/2018 and 1/14/2019 in the patient's chart. The finding was verified with the DON on 1/15/19 at 12:40 PM.

Hospital policy, titled, "Restraint Use", reads, "....A physician's order is required to initiate, change, and discontinue restraint....the order must include the type and number of restraints and duration....any order that varies from hospital policies and procedures for monitoring of the patient and for release from restraint before the order expires must contain a rationale....Orders....a. Restraints used to ensure the physical safety of the non-violent or non-self destructive patient are renewed daily....b. A face to face assessment of the patient by the attending physician is documented daily following initiation of restraints and before renewal of restraint orders....".

Based on record reviews and interview, the hospital failed to show the hospital used data collected from its incident reports in an ongoing measurable improvement program that will improve health outcomes for wound care.

The findings are:

On 1/17/2019 at 8:00 p.m., review of the hospital's adverse events/incident reports revealed 5 occurrence from May 2018 through November 2018 where staff had not completed the patient's wound care per physician orders. The incident reports were dated 5/16/2018, 7/10/2018, 8/5/2018, 10/31/2018, and 11/1/2018. Registered Nurse (RN) 1 verified the findings, and stated, "We are aware there is a problem with wound care being done." Review of the hospital's Quality Assurance Performance Improvement (QAPI) meeting minutes revealed there was no Process Improvement data regarding wound care. When RN 1 was asked if a performance improvement plan was put in place, RN 1 stated "We did re-education of staff, but I don't have anything documented."

Based on record reviews, interviews, and a review of the hospital's policy, entitled, "Utilization of the BWAT (Bates Jensen Wound Assessment Tool) to Measure Wound Healing", revised 3/2018, the hospital failed to ensure its staff documented the patient's wound care was completed as ordered for 4 of 10 patient charts reviewed (Patient 1, 3, 5, and 7); failed to document the date the patient's dressing was changed on the patient's dressing per hospital policy for 4 of 4 patients requiring wound care whose dressing was observed (Patient 11,12, 13, and 15), treatment orders had not been initiated on admission for a pressure ulcer and surgical abdominal wound for 2 of 10 patient charts reviewed for surgical wound care and services (Patient 8) and for pressure ulcers for Patient 5; 1 of 1 patient did not receive Prostat as ordered for 2 doses (Patient 5); Intake and Output orders had not been followed for 1 of 1 patient with orders for output measurement (Patient 1), 1 of 1 patient with physician orders for "out of bed" dated 1/13/2019 had nursing documentation that showed bed rest for five days after the physician order was written, and 1 of 1 patient interviewed who reported no bath since admission had no nursing documentation of a bath since admission(Patient 5). The hospital failed to ensure 3 of 3 Registered Nurses (RN 4, 5 and 6), and 1 of 1 Certified Nursing Assistant (CNA 1) followed acceptable principles for infection control to prevent the potential cross transmission of infectious agents by failure to change gloves and perform hand hygiene when indicated after touching "dirty" surfaces or during the provision of wound care.


The findings included:


Observations
Patient 6
On 1/15/2019 at approximately 10:15 AM, review of Patient 6's chart showed the patient was admitted on 12/1/18. Observations on 1/15/19 at approximately 11:10 AM revealed Registered Nurse (RN) 6 donned gloves repositioned the patient's legs and moved the patient's pillow that was between the patient's legs. Wearing the same gloves, RN 6 opened a suction catheter kit, donned sterile gloves over that he/she wore when repositioning the patient. Then, RN 6 suctioned the patient's tracheostomy. During an interview on 1/15/19 at 11:30 AM, RN 6 verified that s/he had not removed the soiled gloves or sanitized his/her hands prior to donning sterile gloves to suction the patient.

Observations of wound care for Patient 6 performed on 1/15/19 from 1:45 PM to 2:15 PM by RN 4, a member of the wound care treatment team, revealed inappropriate hand hygiene/and glove changes with the potential risk for infection from cross contamination in the hospital setting.

Observations showed RN 4 donned gloves and removed both heel boot protector boots from the patient's feet and removed the patient's positioning pillow and placed the pillow to the side. RN 4 spread a paper drape under the patient's feet, unfastened the patient's abdominal binder, removed the patient's gastrostomy dressing, and placed the soiled dressing in the trash. RN 4 obtained a wet wipe, cleaned some crusty drainage from the stoma site, and placed the soiled wipe in the trash. RN 4 opened a package of clean gauzes and placed a gauze around the gastrostomy stoma, and then fastened the patient's abdominal binder. The RN 4 retrieved a wet wipe and cleaned some sputum from the patient's chest. RN 4 opened a packet of gauze and placed a gauze under the patient' tracheostomy. Then, RN 4 removed the soiled gloves and sanitized hands.

RN 4 donned a clean pair of gloves, opened and placed clean supplies onto a drape on the overbed table, sprayed the patient's left leg/heel with sterile saline, and used a separate gauze to wipe the wounds, and placed the soiled supplies in the trash. The RN 4 proceded to the patient's right heel, and sprayed saline into the wound. RN 4 held up the patient's right heel while RN 5 measured and took pictures of the heel. RN 4 peeled back the old tissue from the patient's right heel, dabbed the right heel with a gauze to catch some serosanguinous drainage/blood. RN 4 grabbed a piece of the patient's bedding/sheet to assist Certified Nursing Assistant 1 and RN 5 to turn the patient. RN 4 removed the soiled gloves and donned clean gloves.

Observations of wound care to the patient's sacrum revealed RN 4 squirted normal saline onto the patient's sacral wound and wiped the sacral wound with a piece of gauze. RN 4 retrieved a bottle of Dakins solution, contaminated the bottle wearing the soiled gloves, squirted the Dakins on a piece of gauze, and then packed the sacral wound with the Dakins soaked gauze. RN 4 dated the patient's dressing with a sharpie wearing the soiled gloves.

Observation of continued care to the patient's left leg and bilateral heels revealed RN 4 donned clean gloves, placed a medicated gauze onto the patient's left leg and placed a foam pad over the left leg and left and right heels. RN 4 did not change gloves and or perform hand hygiene between care for each wound to prevent possible cross contamination. RN 4 held the patient's left leg while CNA 1 wrapped the patient's leg in kerlix. RN 4 taped the kerlix and dated the dressing. Without changing gloves or performing hand hygiene, RN 4 proceeded to the wound on the patient's back(left upper) and wiped the wound with a Dakins soaked gauze. Wearing the soiled gloves, RN 4 touched a button on the bed to adjust air into the mattress and applied a barrier cream to the patient's back side. Observations showed RN 5 placed the contaminated bottle of Dakins Solution in a cabinet at the patient's bedside. After donning clean gloves, RN 4 assisted staff to turn the patient, and without changing gloves and performing hand hygiene, RN 4 picked up the kerlix dressing, wrapped the patient's right heel, taped the right heel dressing, and then used a Sharpie to date the dressing.

Patient 7
Review of Patient 7's chart on 1/15/2019 at 1:15 PM, revealed the patient was admitted on 9/25/18. Observations of wound care to Patient 7's right posterior calf on 1/15/19 at 2:25 PM revealed Registered Nurse (RN) 4 retrieved the patient's medline boots and the pillow from the patient's bed, and placed the boots and pillow in a chair. Wearing the same gloves that had touched the patient's equipment, RN 1 picked up a clean gauze and Normal Saline. RN 1 handed the gauze and Normal Saline to RN 5, a nurse on the hospital's wound care team, who sprayed the Normal Saline on the patient's wound and used a gauze to clean the patient's wound with the potenitally contaminated supplies.

Patient 3
Review of Patient 3's chart on 1/16/2019 at 12:10 PM revealed Patient 3 was admitted on 1/9/19. Observations on 1/15/19 at approximately noon revealed RN 4 removed soiled gloves and without performing hand hygiene donned clean gloves and taped the patient's catheter to his/her leg. RN 4 wrapped kerlix and packed the patient's perineum with gauze. RN 4 placed a foam dressing over the patient's dressings. RN 4 removed the soiled gloves, and without performing hand hygiene, donned clean gloves, and documented on the computer touching the keyboard. The findings were reviewed and verified with RN 4 on 1/15/19 at 2:45 PM.

Record Reviews
Patient 3
On 1/16/2019 at 12:10 p.m., review of Patient 3's chart revealed the patient was admitted on 1/9/19 with a physician order for daily wound care to the perineum that read, "Perineum wound-cleanse w(with)/normal saline and pat dry. Cover penis shaft w/collagenase ointment then cover w(with)/Xeroform.....wound bed pack w/wound gel saturated 4 x(by) 4's, cover w/ABD(dressing) or foam, secure w/tape...". Review of nursing documentation dated 1/12/2019 and 1/13/2019 revealed there was no documentation to show the patient's wound care orders were implemented by the nursing staff for wounds to the perineum on those dates. The finding was verified with RN 3 on 1/16/19 at 12:38 PM.

Patient 7
On 1/16/2019 at 11:00 AM, review of Patient 7's chart revealed the patient was admitted on 9/25/18. Review of documentation dated 12/27/18 at approximately 11:00 AM revealed a Wound Team Visit note that reads, "New ulcer (non-pressure) noted to right posterior calf. Alginate to be applied QOD (Every Other Day) and prn (As needed)...". Documentation showed the wound measured "4 x 1.3" centimeters.
Review of physician orders dated 12/27/18 revealed "right posterior calf- cleanse area with normal saline, apply Melgisorb, and cover with small Mepilex border. CHANGE QOD AND PRN IF SOILED OR DISLODGED." The frequency for the dressing changes was documented as 72 hours frequency instead of 48 hours (QOD) frequency that the physician ordered. During an interview on 1/16/19, Registered Nurse (RN) 2 stated that he/she thought the nurse putting in the physician order in the computer system had put the 72 hour frequency in error. Documentation of wound care revealed there was no wound treatment documented for the right posterior calf from 12/29/18 until 1/3/19. Wound care treatments were documented as completed on 1/3/19, 1/6/19, 1/9/19, 1/10/19, and 1/13/19 which was every 72 hours and not every other day as ordered by the physician. Review of the nurse's documentation on 1/6/2019 revealed the nurse documented "a moderate amount of purulent drainage" which was a change from baseline for the wound, but there was no documentation of notification to either the wound team or physician of the purulent drainage. During an interview on 1/17/19 at 4:37 PM, Registered Nurse 2 stated the hospital had no procedure in place for notifying the wound team of purulent drainage or changes to the wounds. The findings were verified with RNs 2 and 3 on 1/16/19 at 11:30 AM.

Patient 8
On 1/16/2019 at 3:30 PM, review of Patient 8's chart revealed the patient was admitted on 1/12/19. Review of the nurse's admission assessment dated 1/12/19 at 5:24 PM revealed "Has pressure ulcer, open, or non-healing wound and - or total Braden score of 16 or less...". There was no documentation of the wound location, size or stage, or if a dressing/treatment had been applied to the site. There was no documentation that the physician was notified for orders for the pressure ulcer upon the patient's admission. Review of the patient's Admission History and Physical, dated 1/12/19, revealed no documentation of a pressure ulcer, but did state the patient had a surgical abdominal wound. Review of the physician's "Assessment/Plan" showed "Wet to dry dressings BID (twice daily) and a wound care consult". There were no physician orders written for the wet to dry dressings bid and no documentation that nursing consulted the physician for orders for the patient's surgical wound care or pressure ulcer wound care.

Review of a nurse note dated 1/13/19 at 3:32 PM revealed "Appears to be a skin tear. Creme and sacral border placed. New admit yesterday." There was no documentation on 1/13/2019 that the nurse notified the physician for orders for treatment for the pressure ulcer although the nurse documented a creme and sacral border had been placed.

Review of the patient's chart revealed the wound care nurse(s) evaluated the patient on 1/14/19 and documented "left buttock pressure ulcer on admission, stage 3 measuring 0.7 x 1.0 superior, 0.7 x 1.0 inferior; and an abdominal surgical wound measuring 15.5 x 24 x 8 (centimeters).

During an interview on 1/16/18 at 3:45 PM, RN 3 verified the findings. RN 3 reported that nursing usually applies a Mepilex to each patient's sacrum and heels on admission to prevent any break down in these areas. RN 3 verified there was no documentation in the patient's chart that Mepilex was applied to the patient's wounds on admission. When asked if there is a hospital protocol or hospital policy to apply Mepilex to wounds, RN 3 reported that it is common knowledge among the nursing staff, but there is no written policy that this be done or documented.

During an interviews on 1/17/19 at 12:37 PM and 2:50 PM, RN 2 verified the findings. RN 2 reported nursing documented in the patient's assessment that the patient had a broken area on admission as well as the abdominal wound. RN 2 reported the admitting physician usually does a head to toe assessment and initiates orders related to any treatments for wounds. RN 2 reported the wound team nurses do an assessment of the patient on admission, but if the patient is admitted late on a Friday, the wound care team would not see the patient until the following Monday. RN 2 reported the wound care team does not work on weekends. RN 2 reported the hospital has no standing orders or protocols for nursing for initiating treatments for wounds. RN 2 reported that nursing would have to call the physician for orders for wound care.

Patient 5
On 1/16/2019 at 12:45 PM, review of Patient 5 revealed the patient was admitted to the hospital on 12/28/18. Review of an nursing admission note dated 12/28/18 at 3:00 PM revealed, "...Patient wounds assessed. Sacral Wound x 1, Ischial Wound x 2...". There were no measurements or stages of the wounds documented by nursing on admission. There were no physician orders for wound care for the pressure ulcers and no documentation that nursing had notified the physician of the pressure wounds or requested orders for the pressure wounds. There was no documentation that nursing performed any wound care from 12/28/2018 until 12/31/2018. Review of Patient 5's chart revealed physician orders dated 12/31/18 at 4:16 PM for daily treatments to wounds to the left buttock, right ischium, sacrum, and left ischium.

On 12/31/18, documentation showed the Wound Team's assessment revealed Patien 5 had 4 wounds: Stage 4 sacral pressure ulcer measured 9.5 x 19.5 x 1.8; left buttock unstageable pressure ulcer measured 0.3 x 0.6 x 1.2 x 2.3; left Ischium stage 4 pressure ulcer measured 3.2 x 2.8 x 0.5; and right Ischium stage 4 pressure ulcer that measured 4 x 3.5 x 0.5. Review of the hospital's policy, entitled, "Utilization of the BWAT (Bates Jensen Wound Assessment Tool) to Measure Wound Healing, Revised 3/2018, reads, "...The BWAT should be completed initially and at regular intervals (at least weekly) to evaluate intervention effectiveness...".

Documentation in Patient 5's chart revealed the wound measurements were not documented until 1/10/19 when the wound measurements were documented by the Wound Care Team. There was no documentation of weekly wound measurements by nursing or the Wound Care Team.

Review of nursing notes revealed there was no documentation that Patient 5's wounds were evaluated and treated on 1/2/19, 1/3/19 to the left buttock and right ischium, 1/5/19, 1/7/19, and 1/15/19. There were no nursing notes as to why the ordered treatments were not implemented on those dates. The findings were verified with RN 3 on 1/16/19 at 1:31 PM.

Review of the admission nutrition assessment dated 12/31/18 revealed Patient 5's Albumin was 3.2 as of 12/29/18. The patient was ordered Juven on admission to assist with wound healing. Review of the "Nutrition Monitoring" note dated 1/7/19 revealed the patient disliked Juven, and the Juven would be discontinued, and the patient would receive Prostat twice daily. Review of the physician order dated 1/7/19 showed the patient was ordered 1 packet of Prostat twice daily. Review of nursing documentation revealed the patient did not receive the Prostat on 1/7/19 and 1/8/19 for the 9:00 PM doses, and there was no reason documented for the missed doses. The findings were verified with RN 3 on 1/16/19 at 2:25 PM.

Hospital Policies
A review of the policy provided by the facility, entitled, "Hand Hygiene and Artificial Nail Policy" (Revised 3/18), reads, "alcohol based hand rubs should be used in situations including: before donning sterile gloves, before performing any non-surgical invasive procedures, before handling clean or soiled dressings, gauze pads, etc., before moving from a contaminated body site to a clean body site during resident care, after contact with the resident's intact skin, after handling used dressings, contaminated equipment, etc., after contact with inanimate objects (e.g. medical equipment) in the immediate vicinity of the resident; and after removing gloves...The use of gloves does not replace handwashing/hand hygiene. According to the policy, handwashing should be completed in situations including: after contact with blood, body fluids, secretions, mucous membranes, or non-intact skin; and after handling items potentially contaminated with blood, body fluids, or secretions."



39463

On 1/16/2019 at 2:55 p.m., random observations of wound dressings for Patient 11/12/13/and 15 revealed hospital staff had not dated the wound care dressings per hospital policy when changed. On 1/16/2019 at 2:55 p.m., observations of Patient 11 revealed the patient's left heel dressing was not dated when applied. On 1/16/2019, Registered Nurse (RN) 4 verified the finding On 1/16/2019 at 3:15 p.m., observations of Patient 12's sacral dressing revealed the sacra dressing was not dated when changed, and the patient's left Ischial dressing had no date when applied. On 1/16/2019 at 3:45 p.m., observations of Patient 13 revealed the patient's right heel dressing had no date when applied. On 1/16/2019 at 4:00 p.m., observations of Patient 15 revealed the patient's right heel dressing was not dated when applied. On 1/16/2019 at 3:15 p.m., 3:45 p.m., and 4:00 p.m., RN 4 verified the findings, and stated "The policy is to date them when dressing is changed or applied."

On 1/17/2019 at 5:00 p.m., review of Patient 4's chart revealed a physician order dated 1/13/2019 that read, "Out of bed to chair daily." Review of nursing notes in the "patient activity" section dated 1/14/2019, 1/15/2019, 1/16/2019, and 1/17/2019 revealed "bed rest". RN 2 verified the findings.

On 1/17/2019 at 3:40 p.m., RN 4 stated, "Every patient should get a bath everyday. If the patient refuses it should be documented." Review of Patient 5's chart revealed the patient was admitted on 12/28/2018, and no baths were documented for the patient. RN 4 reviewed the patient's notes and stated, "You are right, I can't find any baths charted. I haven't found a bath on her."

Based on observations, interviews, and a review of the policy entitled "Hand Hygiene and Artificial Nail Policy" (Revised 3/18), the facility failed to ensure 3 of 3 Registered Nurses (RN 4, 5 and 6), and 1 of 1 Certified Nursing Assistant (CNA 1) followed acceptable principles for infection control to prevent the potential cross transmission of infectious agents by failure to change gloves and perform hand hygiene when indicated after touching "dirty" surfaces or during the provision of wound care.


The findings included:


The facility admitted Patient #6 on 12/1/18. Observation on 1/15/19 at approximately 11:10 AM revealed Registered Nurse (RN) 6 with gloved hands repositioning the patient's legs and moving the patient's pillow that was between the patient's legs. With the same gloved hands, the nurse opened a suction catheter kit, donned the sterile gloves over the gloves used to reposition the patient, and suctioned the patient's tracheostomy. During an interview on 1/15/19 at 11:30 AM, RN 6 verified that s/he had not removed the "dirty" gloves/sanitized his/her hands prior to donning sterile gloves to suction the patient.

Observation of dressing changes/ wound care for Patient 6 on 1/15/19 from 1:45 PM to 2:15 PM revealed a lack of hand hygiene/and glove changes that put the patient at risk for infection due to cross contamination: RN 4 with gloved hands removed both heel boot protector boots from the patient's feet and removed the patient's positioning pillow and placed it to the side. S/he spread a paper drape under the patient's feet. With the same gloved hands, the nurse unfastened the patient's abdominal binder and removed the patient's Gastrostomy dressing and placed it in the trash. After obtaining a wet wipe, s/he cleaned some crusty drainage from the stoma site and placed the wipe in the trash. With the same gloved hands the nurse opened a clean gauze and placed it around the Gastrostomy stoma, and then fastened the patient's abdominal binder. With the same gloved hands, the nurse picked up a wet wipe and cleaned some sputum from the patient's chest. With the same gloved hands s/he opened a new gauze and placed it under the patient' tracheostomy. RN #4 then removed his/her gloves and sanitized his/her hands. S/he then donned a clean pair of gloves, and after opening clean supplies onto a drape on the over bed table, sprayed the patient's left leg/heel with sterile saline, and used separate gauze to wipe the wounds, and placed the used supplies in the trash. Without changing gloves and/or sanitizing his/her hands, the nurse went to the patient's right heel, and sprayed saline into the wound. RN #4 then held up the right heel while RN 5 measured and took pictures of the heel. RN #4 with the same gloved hands peeled back the old tissue from the right heel dabbing it with gauze to catch some serosanguinous drainage/bleeding. With the "dirty" gloved hands s/he grabbed a piece of the patient's bedding/sheet to assist Certified Nursing Assistant #1 and RN #5 to turn the patient. Observation of wound care to the sacrum revealed RN #4 with clean gloved hands squirting normal saline onto the sacral wound and wiping with a piece of gauze. S/he then picked up a bottle of Dakins solution, contaminating the bottle, and squirted the Dakins on another piece of gauze, and packed the sacral wound with the Dakins soaked gauze. The nurse then dated the dressing with a sharpie using the same gloved hands. Observation of continued care to the patient's left leg and bilateral heels revealed RN #4 with clean gloves placing a medicated gauze onto the patient's left leg and foam pad over the left leg and left and right heels. RN #4 did not change gloves/sanitize hands in between care for each wound to prevent possible cross contamination. RN #4 then held the patient's left leg while CNA #1 wrapped it in Kerlix. After taping the Kerlix and dating the dressing, and without changing gloves/sanitizing his/her hands, RN #4 went to the patient's back wound (left upper) and wiped it with Dakins soaked gauze. With the same gloved hands s/he touched a button on the bed to adjust air into the mattress and applied barrier cream to the patients back side. RN #5 was observed placing the contaminated bottle of Dakins Solution in a cabinet at the patient's bedside. RN #4 was observed with clean gloved hands assisting the staff to turn the patient. With the same gloved hands, s/he picked up some Kerlix dressing and wrapped the patient's right heel, taped, and dated it with a sharpie.

The facility admitted Patient #7 on 9/25/18. Observation of wound care to Patient #7's right posterior calf on 1/15/19 at 2:25 PM revealed Registered Nurse (RN) #4 picked up the patient's medline boots and positioning pillow from the bed and placed them in a chair. With the same gloved hands that had touched "dirty" patient equipment, RN #1 then picked up a clean gauze and Normal Saline and handed them to RN #5 who sprayed the Normal Saline and used the gauze to clean the patient's wound.

The facility admitted Patient #3 on 1/9/19. Observation on 1/15/19 at approximately noon revealed RN #4 removing "dirty" gloves and without sanitizing his/her hands, donned clean gloves and taped the patients catheter to his/her leg. S/he wrapped Kerlix and packed the patient's perineum with gauze. S/he then placed a foam dressing over the patient's dressings. RN #4 then removed gloves, and without sanitizing his/her hands, donned clean gloves, and documented on the computer touching the keyboard.
The above findings were reviewed and verified with RN #4 on 1/15/19 at 2:45 PM.

A review of the policy provided by the facility, entitled, "Hand Hygiene and Artificial Nail Policy" (Revised 3/18), alcohol based hand rubs should be used in situations including: before donning sterile gloves, before performing any non-surgical invasive procedures, before handling clean or soiled dressings, gauze pads, etc., before moving from a contaminated body site to a clean body site during resident care, after contact with the resident's intact skin, after handling used dressings, contaminated equipment, etc., after contact with inanimate objects (e.g. medical equipment) in the immediate vicinity of the resident; and after removing gloves...The use of gloves does not replace hand washing/hand hygiene. According to the policy, hand washing should be completed in situations including: after contact with blood, body fluids, secretions, mucous membranes, or non-intact skin; and after handling items potentially contaminated with blood, body fluids, or secretions."