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Based on observation, staff (EMP) interview, and review of medical records (MR), it was determined nursing staff failed to perform wound care in a manner consistent with infection control policies and procedures in two (2) of two (2) wound care observations (MR9 and MR11).

Findings:

The surveyor observed EMP3 perform wound care on MR9 at 1:50 PM on June 9, 2025. EMP9 set up clean supplies on a bedside table without cleaning and disinfecting the table and on the patient's bed. EMP9 removed the old dressing, performed hand hygiene and donned clean gloves. Then EMP3 reached for the patient's oral suction catheter to give to the patient, went to a storage area in the patient's room to retrieve a wound measuring tool, obtained measurements of the patient's wound, input measurements into a shared tablet device, and resumed care of the patient's wound to include cleaning the wound bed with bone exposed all without changing gloves or performing hand hygiene.

The surveyor observed EMP13 perform wound care on MR11 at 9:50 AM on June 10, 2024. EMP13 performed hand hygiene and donned clean gloves. EMP13 removed the soiled dressing, cleansed the wound with wound cleanser, opened the clean dressing and placed the open dressing on a bedside table that had not been previously cleaned and disinfected, and placed the dressing on the wound without performing hand hygiene or changing gloves.

An interview was conducted with EMP6 at 10:00 AM on June 10, 2025. EMP6 confirmed gloves should be changed and hand hygiene performed during wound care when moving from contaminated body sites to clean body sites and contaminated gloves should not be worn while touching clean supplies in the patient's environment.

The facility's policy, Hand Hygiene (last reviewed February 20, 2025) was reviewed and reads in part, "...Indications for hand washing and hand antisepsis...Before and after patient contact, providing care or treatment, and before entering and exiting a patient room or environment...change gloves and perform hand hygiene during patient care if moving from a contaminated body site to a clean body site..."

Based on observation, interview and document review, it was determined facility staff failed to follow transmission-based precautions as required in facility policy for a patient with MRSA.

The findings include:

Review of MR9 revealed the patient had a stage IV pressure ulcer to the sacral area with exposed bone and MRSA (methicillin-resistant staphylococcus aureus, a type of staph infection that is difficult to treat) infection in the wound. MR9 was on contact precautions due to the MRSA infection and was receiving negative pressure wound therapy (a device that applies suction to promote wound healing) with a dressing change three times per week.

MR9 was on contact precautions for MRSA of the wound. Facility policy required anyone who entered the patient's room to wear personal protective equipment (PPE) to include a gown and gloves. During wound care observations on MR9 at 1:50 PM on June 9, 2025, EMP14 came into the room without wearing any PPE. Prior to wound care observations at approximately 1:45 PM on June 9, 2025 EMP15 was observed leaving the patient's room in PPE to include gloves and gown, not performing hand hygiene, and standing in the hallway with shared vital sign equipment.

An interview was conducted with EMP6 at 10:00 AM on June 10, 2025. EMP6 indicated that PPE to include gown and gloves must be worn by anyone entering a patient room on contact isolation and should be removed prior to leaving the patient's room.

The facility's policy, "Standard and Transmission-Based Precautions" last revised November 13, 2023 was reviewed and reads in part, "...Contact precautions, in addition to standard precautions, will be used for patients known or suspected to be infected with epidemiologically important microorganisms that can be transmitted by direct contact with the patient or indirect contact with environmental surfaces associated with the patient. Wear gloves and/or gowns as patient care tasks dictate in accordance with standard precautions. When direct contact with patient or patient's environment is anticipated, apply appropriate barrier..."

The facility's policy, Hand Hygiene (last reviewed February 20, 2025) was reviewed and reads in part, "...Indications for hand washing and hand antisepsis...Before and after patient contact, providing care or treatment, and before entering and exiting a patient room or environment...change gloves and perform hand hygiene during patient care if moving from a contaminated body site to a clean body site..."

Based on observation, interview and document review, it was determined the facility's infection preventionist failed to conduct audits of adherence to infection prevention and control policies and procedures by hospital personnel.

The findings include:

The surveyor observed EMP3 perform wound care on MR9 at 1:50 PM on June 9, 2025. EMP9 set up clean supplies on a bedside table without cleaning and disinfecting the table and on the patient's bed. EMP9 removed the old dressing, performed hand hygiene and donned clean gloves. Then EMP3 reached for the patient's oral suction catheter to give to the patient, went to a storage area in the patient's room to retrieve a wound measuring tool, obtained measurements of the patient's wound, input measurements into a shared tablet device, and resumed care of the patient's wound to include cleaning the wound bed with bone exposed all without changing gloves or performing hand hygiene.

The surveyor observed EMP13 perform wound care on MR11 at 9:50 AM on June 10, 2024. EMP13 performed hand hygiene and donned clean gloves. EMP13 removed the soiled dressing, cleansed the wound with wound cleanser, opened the clean dressing and placed the open dressing on a bedside table that had not been previously cleaned and disinfected, and placed the dressing on the wound without performing hand hygiene or changing gloves.

An interview was conducted with EMP6 at 10:00 AM on June 10, 2025. EMP6 indicated that the facility does not currently conduct audits or observations specific to wound care and infection control.