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Based on record review and interview facility's registered nurse failed to ensure nutritional supplement prescribed for 1 of 7 sampled patients. Patient #1.

Findings:

Review of Patient #1's clinical record (History and physical dated 08/12/2023 ) revealed the patient was admitted to the facility on 08/11/2023 with admitting diagnosis past medical history significant for atrial fibrillation, nonischemic cardiomyopathy, s/p LVAD -2018, sick sinus syndrome, s/p AICD, chronic driveline infection, secondary to Klebsiella and Enterobacter bacteremia, chronic anemia, ESRD on hemodialysis, breast/fallopian tube cancer, hypothyroidism, and gout.

Description of wounds from pictures taken 08/11/2023 at 21:00
(1) Wound sacrum: Pressure injury stage 2 length 3 cm, width 3 cm, wound surface area 9 cm ^ 2 with fibrin slough serosanguineous drainage.
(2) Pressure injury right heel stage 1 pink
(3) Skin tear right pelvic
(4) Pressure injury midline spine lumbar, wound appearance dry; red, pressure injury stage 1
(5) Pressure injury midline back, stage 1 wound appearance pink

Nutritional Assessment:
Review of the patient's clinical record revealed a nutritional assessment dated 08/17/2023 with the following findings:
"Malnutrition diagnosis: Patient meets criteria for severe protein -calorie malnutrition. Current degree of malnutrition was present on admission:

Nutrition -Focused Physical Examination: (NFPE)
Body Fat Assessment: orbital: Hollow look, scooping, depression. Clavicle Protruding. Prominent bone. Acromion Process: Shoulder Squaring, shape angles, intraosseous: slightly depressed.
Malnutrition Diagnosis Parameters:
Energy intake < 75% of estimated needs for > 7 days
Weight loss does not fit parameter.
Body Fat losses: Severe
Muscle losses: Severe
Fluid Accumulation: Moderate
Functional Status: Ability to complete ADLS measurably reduced."


Review of patient #1's clinical record revealed the following physician's order:
08/11/2023 nutritional supplement of Novasource one daily.
08/13/2023 Banatrol powdered supplement twice daily.
0814/2023 Banatrol powered supplement three times daily.

Review of the patient's clinical record revealed the following documented laboratory result:
08/11/2023: albumin 2.9
08/29/2023: albumin 2.2 gms/ dl, reference range 3.5 -5.5 g/dl
08/12/2023: Protein 5.1 g/dl, reference range 6.3- 8.3 g/dl

Review of the patient's clinical record revealed no documentation that nutritional supplement of Novasource one daily and Banatrol powered supplement three times daily were administered on 08/23/2023, 08/24/2023 and 08/25/2023.
There was no justification documented why the nutritional supplements were not administered.

Interview on 10/03/2023 with the Facility's Quality Manager revealed she said fluids were documented as administered but the record did not indicate nutritional supplements.

Interview on 10/03/2023 with the Facility's Quality Manager revealed she said fluids were documented as administered but the record did not indicate nutritional supplements.

Based on observation, Interview and record review, the facility failed to implement its policies and procedures to ensure facility's direct care staff remove contaminated gloves and wash/ sanitize hands while providing hemodialysis treatment, central venous catheter care, medication preparation/ administration and wound care to patients in 2 of 4 staff observed providing hemodialysis treatment, central venous catheter care, medication preparation/ administration and wound care to patients: Registered Nurse (B) and Physical Therapist (C)

Findings:

Review of the facility's current Policy and Procedure on Hand Hygiene and Artificial Nails; Policy # PCPS134, revised 1/2021, directs staff as follows:"
"Policy and General Statement: appropriate hand hygiene practice is the single most important factor in preventing the transmission of pathogens, some of which could be multi- drug resistant organisms, in healthcare settings. Strick adherence to hand hygiene practices has a direct correlation with reduction in incidence of healthcare acquired (HAIs), and therefore, directly contributes to patient safety.
Proper use of gloves during patient care can also prevent transmission of infectious agents in high- risk situations. Proper gloving practices protects patients and healthcare providers alike."
4.1 Hand Hygiene is indicated:
4.11 At the start of shift
4.1.2 Upon entering a patient's room, even if patient contact is not anticipated.
4.1.3 Patient Zone (WHO 5 moments - see appendix B) for illustration);
4.3.11 Before touching a patient.
4.1.3.2 Before clean/ aseptic procedure
4.1.3.3 After body fluid exposure risk - After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings, even if gloves were worn.
4.1.3.4 After touching a patient
4.1.3.5 After touching a patient's surroundings.
4.1.4 Before donning gloves and after glove removal, even if there is no patient contact.
4.1.5 Before moving from a contaminated -body site to a clean -body site during patient care, even if gloves were worn.
4.1.6 After contact with inanimate objects (including medical equipment) or environmental surfaces in the immediate vicinity of a patient, even if gloves were worn.
4.1.7 Upon exiting a patient's room, even if there was no contact with the patient or patient's surroundings. It is acceptable for a healthcare provider to perform hand hygiene after exiting a patient's room and immediately enter another patient's room (adjacent or nearly adjacent ) without having to sanitize hands again. The healthcare provider must not touch any surface in the interim."

Patient #2
Observation on 10/02/2023 12:20 p.m. of patient #2 in her room revealed the patient was receiving hemodialysis treatment at a blood flow rate of 350 mls/ minute and dialysate flow rate of 700 mls/ minute via a right jugular intra catheter.
Observation on 10/02/2023 at 12:20 p.m. revealed Registered Nurse (B) was observed in patient #2's room. The registered nurse was providing hemodialysis treatment to patient #2.

Observation revealed Registered Nurse (B) was wearing a pair of gloves. The registered used her gloved hands and reset the panel on the patient's hemodialysis machine, then walked over to the computer located outside the door of the patient's room and accessed/ entered information in the computer with her contaminated gloved hands.
After accessing the computer, Registered Nurse (B) picked up a pair of clean gloves from the box of gloves stored on the wall near the patient's room door, donned it over the existing contaminated gloves.
The registered nurse did not remove her contaminated gloves and wash/ sanitize her hands.

The registered nurse removed the outer gloves from her hands, picked up clean gloves from the box of gloves stored on the wall near the patient's room door, examined the patient's vascular access site (central venous catheter/ intra catheter ), removed the outer layer gloves from her hands and entered information in a tablet, then entered information in the computer with her contaminated gloves.
The registered nurse did not remove her contaminated gloves and wash/ sanitize her hands.

Medication preparation/ Administration; Central Venous Catheter Care
Review of the facility's current Policy and Procedure on Medical Administration by Registered Nurses and other Licensed Healthcare Professionals; Policy and Procedure # PHA 005, revised 8/23, directs healthcare providers as follows:
"Aseptic technique should be used when opening ampules and/or entering vials."

Review of the Facility's Current policy and procedure on Vascular Access -Hemodialysis Catheters Policy 3# PCP 147.3; reviewed 10/21 directs staff as follows:
"De-Accessing or Disconnecting from a Hemodialysis Catheter
1. Perform hand hygiene.
2. The nurse and patient as applicable should wear a face mask.
3. Don new gloves
4. Using Chlorhexidine pad, disinfect the connection prior to disconnection.
5. Clamp the catheter before disconnecting syringe or tubing.
6. Using a new Chlorhexidine pd, disinfect the hub by scrubbing the sides and end of the hub for 10 to 15 seconds. Use friction making sure to remove any blood residue.
7. Once disinfected, do not allow the catheter hub to touch nonsterile surfaces. Hold the catheter until the antiseptic has dried.
8. Flush the limbs with 10 mls of sterile saline and attach a new sterile cap. Always remember to clamp the catheter before disconnecting from the catheter limb.
9. The catheter may be packed with heparin, as ordered by the physician.
10. Repeat steps 2-9 with the alternate hub of the catheter using new Chlorhexidine pads."

Registered Nurse (B)
On 10/02/2023 at 1:15 p.m. Registered nurse (B) was observed terminating patient #2's hemodialysis treatment in the patient's room. The patient had an intra jugular double lumen central venous catheter ( intra catheter) in place by which she receives hemodialysis treatment.
Observation revealed Registered Nurse (B) donned a pair of clean gloves from a box of gloves stored on the wall adjacent to the door of the patient's room, removed the cap from a multidose vial of Heparin which she prepared on top of the patient's hemodialysis machine. She then entered the vial with a syringe.
The registered nurse did not clean the septum of the vial prior to pulling up and preparing the medication in the syringe to pack to the patient's central venous catheter.

Registered Nurse (B) after preparing the Heparin. disconnected the patient's central venous catheter/ intra catheter from the external blood lines and flushed the catheter with Normal Saline. She did not scrub the hub of the patient's central venous catheter/ intra catheter before disconnecting the catheter from the external blood line. After flushing the patient's central venous catheter, Registered Nurse (B) packed both ports of the limbs of the central venous catheter with the Heparin.

After packing the ports of the intra jugular central venous catheter with Heparin, Registered Nurse (B) cleaned the hub of the central venous catheter and applied clean caps to the limbs of the catheter.

Registered Nurse (B) removed the external blood lines and dialyzer from the hemodialysis machine, picked up clean gloves from a box of clean gloves stored near to the patient's room door, applied the clean gloves over her existing gloves in preparation for terminal cleaning of the hemodialysis machine.

The Hemodialysis Clinical Coordinator was present during the observation. The Surveyor requested an interview with Registered Nurse (B) prior to terminal cleaning.

During an interview on 10/02/2023 with Registered Nurse (B) in the presence of the Hemodialysis Clinical Coordinator, the Surveyor informed Registered Nurse (B) of the break in infection control technique of double gloving, not removing contaminated gloves and wash/ sanitize hands and cleaning the septum of the hemodialysis Heparin vial before entering the vial with the syringe.

Registered Nurse (B) said "The jell is outside."


Wound Care Physical Therapist (C)
On 10/02/2023 at 1:50 p.m. Physical therapist (C) and Rehabilitation Assistant (D) were observed in Patient #2's room. Physical Therapist (C) and Rehabilitation Assistant (D) created a clean field with supplies on the patients over bed table in preparation for wound care of the patient.

The Physical Therapist and Rehabilitation Assistant were providing wound care to the patient who had a wound to her sacrum with a wound vacuum attached and wounds on right ischium and left ischium.

Observation revealed Physical Therapist (C) donned two pairs of clean gloves from boxes of gloves stored on the wall holder near the patient's room door.
After donning the gloves, Physical Therapist (C) turned off and disconnected the wound vacuum and with the assistance of Rehabilitation Assistant (D), repositioned the patient on her left side in bed. After repositioning the patient, observation revealed the patient had a bowel movement.

Physical therapist (C) cleaned the bowel movement from the patient's anus, removed the outer gloves which she used to clean the patient's anus while the inner gloves remained donned. She picked up clean gloves from gloves stored on the clean field of the patient's overbed table. Physical Therapist (C) did not remove both pairs of gloves and perform hand hygiene after cleaning bowel movement from the patient's buttocks.

Physical Therapist (C) donned clean gloves over the pair of existing gloves she wore, removed the soiled dressing from the patient's sacrum and ischium, removed one pair of the gloves and picked up a pair of clean gloves stored on the clean field, donned the gloves, cleaned and debrided the woundbed of the sacral wound which contained yellow slough material.

After debriding the wound, she cleaned the wound, applied a sponge and applied the wound vacuum, taped and applied an occlusive dressing to the patient's sacrum. After securing the occlusive dressing to the patient's sacrum, Physical Therapist (C) removed the outer pair of gloves and donned clean gloves over the existing gloves used to debride the wound. Physical Therapist (C) did not remove both gloves and wash/ sanitize her hands.

After securing the occlusive dressings, the patient had another bowel movement. Physical Therapist (C) cleaned the feces from the patient's anus, removed the outer pair of gloves while the inner pair remained donned. She picked up clean gloves from a box of gloves on the wall and donned them over the existing gloves, repositioned the patient in bed. She repositioned the patient on her right side, and removed an occlusive dressing used to protect the patient's skin on her right ischial area.

After repositioning the patient, a glove fell to the floor Physical Therapist (C), retrieved the glove from the floor, discarded it in the garbage bin, picked up the bin with her gloved hands, repositioned the garbage bin from the left side of the room to the right side of the room.
She then removed her soiled outer gloves and applied clean gloves from a box of gloves. She did not remove the inner pair of gloves and wash/ sanitize her hands.

During an interview outside the patient's room on 10/03/2023 immediately after the observation with Physical Therapist (C), the Surveyor in the presence of the Facility's Nurse Manager informed (Physical Therapist) (C), the Surveyor informed Physical therapist (C) of the break in infection control technique of double gloving, not removing contaminated gloves and wash/ sanitize hands.
Physical therapist (C) states: "The gloves are hard to get off because of moisture from the hand gel"