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Based on record review and interview staff failed to perform a comprehensive root cause analysis, trending to identify any commonalities, develop and implement an action plan, and evaluate the plan for effectiveness for hospital acquired pressure ulcers in 2 of 3 months of quality improvement measures reviewed (October 2017, November 2017).

Findings include:

Review of policy titled, "Quality Assessment and Performance Improvement Plan (QAPI)" last revised 1/2017 revealed,
1. Based on the objective measurement of the performance of existing processes and outcomes, the organization will display data from measurement using appropriate statistical methods and tools to enhance interpretive analysis. Analysis of the collected data includes:
-Assessment of the current level of performance and the stability of the process measured;
-Identification of areas for improvement;
-Determination of root causes for current performance;
-Evaluation of performance improvement strategies, design;
-Formulation and improvement of standards of care, standards of practice and performance standards.

Review on 1/16/18 at 3:00 pm of Hospital Acquired Pressure Ulcer Incident report shows the following:

On 10/2/2017 at 1:15 pm Patient 7 developed a new hospital acquired stage II pressure injury. Chief Nurse Officer B's Note revealed, "Will speak with WCN (Wound Care Nurse) and DQM (Director of Quality Management)." Director of Quality C's note revealed, "We are monitoring staff documentation on wound care, and following up with staff. Staff are informed that continued lack of documentation may result in disciplinary action."

On 10/18/17 at 2:30 pm Patient 8 developed a new hospital acquired pressure injury to right heel. Incident Description revealed staff was unable to determine the source since the patient is "repositioned every 2 hours, always wears prevalon boots, and has bariatric mattress." Chief Nurse Officer B's Note revealed, "no further review needed". Director of Quality C's note revealed, "Patient wears prevalon boots when on the floor. Uncertain if patient obtained (Pressure injury) while down at (hyperbaric treatment)."

On 11/24/17 at 10:00 am Patient 9 developed a new hospital acquired pressure injury. Chief Nurse Officer's Note revealed, "Will organize turn team". Director of Quality C's note revealed, "Staff education ongoing regarding the use of pads on LAL (low airloss) mattresses, and monitoring of turning. CNO (Chief Nursing Officer) will be developing a turning team. Staff who are non-compliant with the patient care policies will be counseled, repeated occurrences of non compliance may lead to the disciplinary process."

Per interview with Director of Quality C on 1/16/18 beginning at 3:00 pm, C was unable to provide documented evidence of the following:
-Performing a root cause analysis to identify reasons for patients developing hospital acquired pressure injuries
-identifying barriers to successful outcomes
-Staff education
-Audits/observations of staff performing skin interventions
-"Monitoring staff documentation" and "follow up with staff"
Per interview with C, the "turning team" has not been developed yet.

Review on 1/16/18 at 3:30 pm of Quality Assurance and Performance Improvement documentation for Hospital Acquired Pressure Injury's shows two new hospital acquired pressure injuries identified in October 2017 and two in November 2017.

Review of November 2017 Quality meeting "Analysis" addressing October 2017 pressure injuries revealed, "Staff are placing incontinence pads on LAL (Low Air Loss) mattresses. There are many new aides and nurses." Plan of Action revealed, "Staff have been educated via multiple ways. Staff safety huddle, individually when found on bed, WCN (wound care nurse) following up with staff. CNO (chief nursing officer) is beginning rounding turns with staff and patients."

Per interview with Director of Quality C on 1/16/18 beginning at 3:30 pm, C stated there was no documented evidence of staff being reeducated as per plan. Per C, Chief Nursing Officer B has not started rounding turns with staff and patients.

Based on observation, record review, and interview staff failed to an ensure a Registered Nurse supervises, assesses, and evaluates all patient care needs in 3 of 10 medical records reviewed (1, 2, 4) and 1 of 1 patient observations (Pt 4).

Findings include:

Review of policy and procedure titled, "Guidelines and Protocols, Clinical" last revised 10/1/2017 revealed the following:
-Systemic physical assessment done and recorded on 24 hours flowsheet every 12 hours and as condition changes
-Patient bathed/hair combed/shaved daily
-Oral care for NPO (no food by mouth), tube feedings, every 4 hours
-Intake and Output (I & O) totaled every shift, 24 hour total by night shift
-Bedfast patients turned every 2 hours, document position
-Mobility level assigned by rehab and nursing within 8 hours of admission and assessed weekly
-Non-bed fast patients OOB (out of bed) to chair BID (twice daily) minimum or per physician's order
-Oral Care for vent patients every 4 hours and PRN (as needed)
-Photo documentation and Wound assessment should be done within 8 hours of admission, weekly and as needed
-Pain assessment and documentation every 4 hours if patient has pain greater then 4/10 until resolved and 30-60 minutes post intervention
-Gastric tube residuals should be checked every 4 hours

Review of policy and procedure titled, "Pain Management, Assessment, and Intervention Protocol" last revised 12/4/17 revealed the following:
-Pain is assessed using the following scales: Numeric Rating Scale (NRS) 0-10 or the Critical Care Pain Observation tool (CPOT) 0-8
-The CPOT scale will be used in patients who are unresponsive or unable to communicate with caregivers
-Research suggests that a NRS rating >3 or a CPOT score >3 indicates significant pain that should be treated
-If pain stated, patient will be assessed about every 4 hours
-Pain will be reassessed 30-60 minutes following a pain reduction intervention
-Revised the management Plan of care if the pain is poorly controlled or interventions are failing to achieve the patients stated pain goal

Review of policy and procedure titled, "Mobility and Weight Bearing Guidelines" last revised 4/1/16 revealed the following:
-Nursing is responsible for ensuring mobility plans are implemented, completed, and documented.
-Level 1 mobility level requires range of motion 4 times daily
-Level 2 mobility level requires range of motion 4 times daily and dangle twice daily
-Level 3 mobility level requires range of motion 4 times daily and out of bed to chair twice daily

Per Patient 4's medical record review on 1/12/18 at 9:45 am of Internal Medicine History and Physical dated 7/18/2017, Patient 4 was admitted to this long term acute care facility on 7/18/17 for "ongoing management of respiratory failure mental status and antibiotics for the left leg osteomylitis." "(Patient 4) is flaccid and weak on left side", "(Patient 4) also required PEG tube placement."

Review of Patient 4's admission orders signed on 7/18/17 time not legible revealed the following:
-Vital signs every 8 hours
-Neurological check every shift
-Input and output (I & O) every shift including tube feeding
-Up with assistance, turn every two hours
-Respiratory mechanical ventilator weaning per protocol
-Heel protection
-Turn every 2 hours

Review of Patient 4's Medical Nutrition Therapy Progress Note documented 12/29/17 at 12:10 pm revealed Patient 4 is on Osmolite 1.2 tube feeding 375 ml bolus 4 time daily (6am, 12pm, 6pm, 12am) with 100 ml (milliter) flushes pre and post bolus.

Review of Patient 4's 24 Hour Patient Record & Plan Of Care documentation from 1/3/18 through 1/7/18 revealed no evidence of nursing staff consistently monitoring and addressing the following patient needs:
-Gastric tube feeding residuals every 4 hours as per policy
-Vital signs every 8 hours as per physician orders.
-Tube feeding administered as per nutritional order.
-Water flushes via PEG tube before and after tube feeding bolus; totaling 200 ml.
-Daily Integumentary (skin) assessment. Per "Pressure Ulcer/Injury Prevention Algorithm", General Skin Care Interventions include a daily skin assessment every shift assessing for alterations in skin integrity, redness, rashes, bruising, and assess skin folds for redness and signs and symptoms of friction.

Review of Patient 4's 24 Hour Patient Record & Plan of Care documentation on 1/3/18 revealed the following:
Pain assessment 6/10 at 8:30 am with a "Critical Care Pain Observation Tool (CPOT)". Plan of care interventions listed as completed at 8:30 am were "education" and "Positioning". No evidence of pain reassessment done until 3:00 pm (6.5 hours later). Pain assessment of 6/10 at 3:00 pm, no pain interventions performed, pain assessment not documented again until 8:04 pm (5 hours later). Pain assessment of 6/10 at 8:04 pm, pain medication given, no evidence of pain reassessment after interventions.

Review of Patient 4's 24 Hour Patient Record & Plan of Care documentation for "Mobility" from 1/3/18 through 1/7/18 revealed a mobility level of 3. Review of Mobility documentation revealed no evidence of Patient 4 consistently performing range of motion exercises 4 times daily as per policy.

Per observations on 1/11/18 at 10:00 am with Chief Nursing Officer B, observed Patient 4's gown and bed pad saturated in urine and feces. Patient 4 did not have on bilateral heel boots to protect heels from potential pressure ulcers/injury per wound care plan of care.

Per interview with Chief Nursing Officer B at the time of observation, Patient 4 should have on heel boots while in bed. Per B, staff should be performing "meaningful" hourly rounding and checking to see if patients who have issues with incontinence are clean and dry, if not, patients should be cleaned at the time of observation.

Per interview on 1/11/18 beginning at 10:35 am with Certified Nursing Assistant G (assigned to Patient 4), G stated Patient 4's last episode of incontinence was addressed on 3rd shift (G works first shift starting at 7:00 am). Per G, Patient 4 was frequently incontinent of urine and stool, but as of 10:35 am, G had not addressed Patient 4's frequent incontinence.

Per Patient 1's medical record review on 1/12/18 at 3:15 pm of Internal Medicine History and Physical dated 10/30/2017 at 4:25 pm, Patient 1 was admitted to the long term acute care facility for ongoing cares status post Metabolic encephalopathy, sepsis, acute respiratory failure, acute chronic back pain, and severe protein calorie malnutrition.

Review of Patient 1's admission orders signed on 10/30/17 at 2:45 pm time revealed the following:
-Weights every am
-Vital signs every 8 hours
-Strict I & O's every shift
-Up with lift to chair
-Tube feeding with 150 cc water flush every 6 hours
-Heel protection
-Turn/reposition every 2 hours

Review of Patient 1's Medical Nutrition Therapy Progress Note documented 10/31/17 at 9:17 am revealed Patient 1 was on Osmolite 1.2 tube feeding at 80 ml/hour with 100 ml water flush every 6 hours.

Review of Patient 1's daily 24 Hour Patient Record & Plan Of Care documentation from 10/30/17 through 1/11/18 revealed no evidence of nursing staff consistently monitoring and addressing the following patient needs:
-Gastric feeding residuals checked every 4 hours
-Vital signs obtained every 8 hours as per physician orders
-Intake and Output (I & O) every shift including tube feeding and supplements
-Daily weight as per physician order
-PEG tube water flushes every 6 hours
-Hair washed/shaved
-Monitoring percentage of food intake for breakfast, lunch, and dinner
-Daily Integumentary (skin) assessment. Per "Pressure Ulcer/Injury Prevention Algorithm", General Skin Care Interventions include a daily skin assessment every shift assessing for alterations in skin integrity, redness, rashes, bruising, and assess skin folds for redness and signs and symptoms of friction.
-Nutritional supplement intake three times daily with meals as per nutritional order

Per interview with Dietician K on 1/16/18 beginning at 10:00 am, K stated nursing staff were not documenting daily weights on patient 1 due to bed scale not functioning properly. Per K, on 12/5/2017 (41 days ago) staff identified inaccuracies with Patient 1's bed scale, K stated Materials was not notified until 1/9/2018 (34 days after the inaccuracies were identified) . Per K, nursing did not consistently document Patient 1's percent of intake at breakfast, lunch, and dinner and the intake of the Ensure supplement ordered with meals. Per K, tube feeding residuals should be checked every 4 hours and nursing staff were not always documenting this. K stated, nursing staff were not consistently documenting administering the required amount of tube feeding, when compared to Patient 1's tube feeding order. Per K, it makes it hard for K to properly assess Patient 1, when staff do not provide accurate documentation.

Per interview with Chief Nursing Officer B on 1/16/18 at 3:00 pm, nursing staff should be following policies and documenting the above information on the 24 hour Patient Record and Plan of Care document as evidence of performing the required nursing duties.

Review of Patient 1's Pain assessments and interventions on the 24 Hour Patient Record & Plan of Care revealed the following:
1/3/18--Pain assessment of 8/10 at 12:30 pm, medication given, no evidence of a pain reassessment until 5:38 pm (more then 5 hours later).
1/4/18--Pain assessment of 8/10 at 10:00 am, medication given, no evidence of a pain reassessment until 10:39 pm (more then 12 hours later).
1/5/18--Pain assessment of 9/10 at 8:30 am, medication given, no evidence of a pain reassessment until 7:00 pm ( more then 10 hours later).
1/9/18--Pain assessment of 9/10 at 8:34 am, no documentation of intervention performed, no evidence of pain reassessment until 9:00 pm (More then 12 hours later).

Review of Patient 2's medical record review on 1/17/18 at 10:00 am revealed per Internal Medicine History and Physical dated 12/21/2017 at 10:34 am, Patient 2 was admitted to long term acute care hospital for wound care, tube feeding, and pain control.

Review of Patient 2's admission orders signed on 12/23/17 at 1:00 pm, revealed the following orders:
-Vital signs every shift
-Weight every am
-Intake and Outputs every shift
-up with assistance
-Osmolite 1.2 continuous at 50ml/hour
-Gastric tube water flushes every 4 hours
-Heel protection
-Turn/reposition every hour

Review of Patient 2's daily 24 Hour Patient Record & Plan Of Care documentation from 12/20/17 through 1/11/18 revealed no documented evidence of nursing staff consistently monitoring and addressing the following patient needs:
-Gastric feeding residuals checked every 4 hours as per policy
-Intake and Output including tube feeding and supplements
-Daily weight
-PEG tube water flushes every 4 hours
-Monitoring percentage of food intake for breakfast, lunch, and dinner
-Daily Integumentary (skin) assessment. Per "Pressure Ulcer/Injury Prevention Algorithm", General Skin Care Interventions include a daily skin assessment every shift assessing for alterations in skin integrity, redness, rashes, bruising, and assess skin folds for redness and signs and symptoms of friction.

Review of Patient 2's 24 Hour Patient Record & Plan of Care documentation revealed the following:
12/21/17--Pain assessment of 10/10 at 9:00 am, medication not documented as given until 10:05 am, no evidence of a pain reassessment until 1:00 pm (3 hours later).
12/23/17--Pain assessment of 7/10 at 10:00 am, pain reassessment not done until 1:00 pm (3 hours later). Pain assessment of 8 at 9:00 pm, pain medication given, no evidence of a pain reassessment completed.
12/25/17--Pain assessment of 9/10 at 8:23 am, pain medication given, no evidence of pain reassessment done until 9:00 pm (more than 12 hours later).
12/26/17--Pain assessment of 6/10 at 11:37 am, no documentation of pain interventions completed, no evidence of pain reassessment until 8:00 pm (more than 8 hours later)
12/30/17--Pain assessment of 9/10 at 7:50 pm, pain medication given, no evidence of a pain reassessment completed.

Per interview with Patient 2 on 1/11/18 beginning at 12:00 pm, Patient 2 stated does not feel nursing staff was doing a good job at managing Patient 2's pain and frequently take a long time to administer pain medication after Patient 2 requests it. Per Patient 2 it took a hour for the nurse to bring Patient 2's pain medication after Patient 1 requested it. Per Patient 2, staff do not frequently reassess Patient 2's pain after administering pain medication.

Review of Patient 2's daily 24 Hour Patient Record & Plan of Care documentation addressing "Self Care and Mobility" from 12/20/17 to 1/11/18 revealed no documented evidence of nursing staff consistently performing required interventions according to daily assigned mobility level. Per plan of care documentation when Patient 2 was assigned mobility level of 3, no evidence was identified of staff getting Patient 1 up to chair BID (twice daily) per mobility plan of care.

Review of Patient 2's daily 24 hours Patient Record & Plan of Care for 12/20/17 through 1/11/18 revealed no evidence of Patient 2 consistently being repositioned every hour per Patient 2's "Pressure Injury Prevention" orders dated 12/20/17 at 2:30 pm.

Review of Patient 2's right heel "Wound Documentation" form revealed Patient 2 should have right heel painted with betadine twice daily. Per review of documentation there was no evidence of Patient 2 having betadine applied twice daily on 12/20/17, 12/22/17, 12/23/17, 12/26/17, 12/27/17, 1/1/18, 1/3/18, 1/4/18, 1/5/18, 1/6/18, 1/7,18, 1/8/18, and 1/10/18.

Based on record review and interview staff failed to ensure a Registered Nurse develops, implements, and evaluates the plan of care for mobility in 5 of 10 medical records reviewed. (Pt 1, 2, 3, 4, 5).

Findings Include:

Review of policy and procedure titled, "Mobility and Weight Bearing Guidelines" last revised 4/1/16 revealed the following:
-Nursing is responsible for ensuring mobility plans are implemented, completed and documented. While Rehab and Respiratory Therapy assist with mobility plan and may document on their discipline specific forms, nursing is responsible for documenting completion of activities.

Review on 1/12/17 beginning at 9:45 am of Patient 1, 2, 3, 4, and 5's Mobility care plan revealed no documented evidence of nursing staff evaluating and addressing patient 1, 2, 3, 4, and 5's daily progression to goals and response to interventions for mobility.

Per interview with Chief Nursing Officer B on 1/16/18 beginning at 3:00 pm, B stated the Mobility care plan is discussed during the weekly interdisciplinary team meeting and addressed by physical therapy and occupational therapy staff. Per B, Registered Nurse did not document a Nursing mobility care plan, including evaluating, updating, and addressing the daily progression to goals or their response to interventions for mobility.

Based on record review and interview staff failed to ensure medical records are complete and entries are signed, timed, and dated in 3 of 10 medical records reviewed (Pt 1, 2, 4).

Findings Include:

Review of policy and procedure titled, "Documentation Standards" last revised 1/1/17 revealed the following:
-All entries must be dated and timed
-Each separate entry must have corresponding time of occurrence in the time column

Review of policy and procedure titled, "Concurrent Analysis of Medical Records" last revised 10/4/17 revealed the medical record should contain the following clinical information:
-Any findings of assessments and reassessments
-Patients response to care and treatment
-any observations relevant to care, treatment, and services
-All orders
-Any progress notes
-Treatment goals, plan of care, and revisions to the plan of care

Review of policy and procedure titled, "Guidelines and Protocols, Clinical" last revised 10/1/2017 revealed the following:
-Patient bathed/hair combed/shaved daily
-Oral care every 4 hours for NPO (no food by mouth) and tubefeeding
-Intake and Output (I & O) totaled every shift, 24 hour total by night shift
-Bedfast patients turned every 2 hours, document position
-Oral Care for vent patients every 4 hours and PRN (as needed)
-Photo documentation and Wound assessment should be done within 8 hours of admission, weekly and as needed

Review of Patient 4's medical record on 1/12/18 beginning at 9:45 am revealed the following:
-"Mechanical Ventilator Flowsheet" for 1/1/18, 1/2/18, 1/3/18, and 1/5/18 revealed "Trach Care/Oral Care was not documented every 4 hours.
-Daily dressing change and assessment "Wound documentation" for 12/13/17, 12/14/17, 1/6/18 and 1/7/18 revealed no time documented.
-Input and output entries do not have specific times documented on 24 hour Patient Record.
-Bath/shower, oral/dental care, Hair washed/shaved, and Peri/Foley care entries on 24 Hour Patient Record do not have specific times documented of when each task was performed; "Complete" was documented in the column.
-Water flush and tube feeding entries do not have specific administration times documented on the 24 Hour Patient Record.

Review of Patient 1's medical record on 1/12/18 beginning at 3:15 pm of the daily 24 Hour Patient Record from 11/15/17 through 1/11/18 revealed the following:
-Input and output entries do not have specific times documented.
-Bath/shower, oral/dental care, Hair washed/shaved, and Peri/Foley care columns do not have specific times documented of when each task was performed; "Complete" was documented in the column.
-Water flush and tube feeding entries do not have specific administration times documented.
-Input and output entries for "shift total" are blank
-Percentage of breakfast, lunch, snack, and dinner columns are blank.
-"Today's Weight" columns are blank

Review of Patient 2's medical record on 1/17/18 beginning at 10:00 am of the daily 24 Hour Patient Record from 12/20/17 through 1/11/18 revealed the following:
-Input and output entries do not have specific times documented.
-Bath/shower, oral/dental care, Hair washed/shaved, and Peri/Foley care columns do not have specific times documented of when each task was performed; "Complete" was documented in the column.
-Water flush and tube feeding entries do not have specific administration times documented.
-Input and output entries for "shift total" are blank
-Percentage of breakfast, lunch, snack, and dinner columns are blank.
-"Today's Weight" columns are blank

Review of Patient 2's dressing change and wound assessment "Wound documentation" form revealed the following:
-Right outer thigh assessment documentation was blank or incomplete on 12/25/17, 12/28/17, and 12/30/17. No times of assessment documented on 12/28/17, 12/29/17, 12/30/17, 1/12/18, 1/13/18, and 1/14/18
-Right heel assessment documentation was blank on 12/21/17. No times of assessments documented on 1/12/18, 1/13/18, and 1/14/18.
-Left upper ischium assessment documentation was blank on 12/20/17, 12/29/17, and 1/14/18. No times of assessments documented on 12/28/17, 12/29/17, 1/12/18, 1/13/18, and 1/14/18.
-Left Buttocks assessment documentation was blank on 12/23/17 and 1/6/18. No times of assessments documented on 12/28/17, 12/29/17, 12/30/17, 1/12/18, 1/13/18, and 1/14/18.
-Right lower extremity assessment documentation was blank on 12/29/17 and 1/13/18. No times of assessments documented on 12/29/17, 12/30/17, 1/3/18, 1/6/18, 1/7/18, 1/12/18, and 1/13/18.
-Abdominal folds assessment documentation was blank on 12/25/17. No times of assessments documented on 12/28/17 and 12/30/17.

Per interview with Chief Nursing Officer B on 1/16/18 beginning at 3:00 pm, B confirmed staff should be documenting all of the above findings.

Based on record review and interview staff failed to ensure all verbal and telephone orders are dated, timed, and authenticated by ordering physician within 24 hours in 4 of 10 medical records reviewed (Pt 1, 2, 3, 4).

Findings Include:

Review of Medical Staff Bylaws on 1/16/18 beginning at 1:00 pm revealed the following:
-The responsible physician for the patient's care shall authenticate, time and date all orders promptly, within the time frame specified by state law..."

Per interview with Chief Nursing Officer B at the time of the review, B revealed physicians should be signing off on verbal orders within 24 hours.

Review of Patient 4's medical record on 1/12/18 beginning at 9:45 am, revealed the following:
-On 11/15/17 at 11:15 am: verbal order for restraints, no physician authentication, time, and date.
-On 9/25/17 no time documented: verbal order for stat labs, no physician authentication, time, and date.
-On 9/12/17 at 6:11 am: verbal order for stat chest X-ray, no physician authentication, time, and date.

Review of Patient 1's medical record on 1/12/18 beginning at 3:15 pm, revealed the following:
-On 11/20/17 at 8:23 am: Verbal order to Discontinue Seroquel and Give Narcan, no physician authentication, time, and date.
-On 12/6/17 at 6:50 am: Verbal order to upgrade diet to general solids, no physician authentication, time, and date.

Review of Patient 2's medical record on 1/17/18 at 10:00 am revealed the following:
-On 12/21/17 at 7:48 am: Verbal order for mechanical soft/nectar thick liquid diet, no physician authentication, time, and date.
-On 12/27/17 at 8:40 am: Verbal order for General diet, not signed by physician until 1/7/18, no time documented.
-On 1/3/28: Physician order to change Dilaudid pain medication, no physician signature and time documented.
-Physician order for labs, no documentation of physician authentication, time, and date.
-1/9/18 at 3:15 pm: Verbal order for wound care, not authenticated by physician until 1/15/18 at 11:00 am.

Review of Patient 3's medical record on 1/17/18 beginning at 11:30 am revealed the following:
-On 12/31/17 at 11:30 am: Verbal order for Hemodialysis, no physician authentication, time, and date.
-On 1/1/18 at 3:30 pm: Verbal order for Restraints, no physician authentication, time, and date.
-On 1/3/18 at 11:45 am: Verbal order for Restraints, no physician authentication, time, and date.
-On 1/12/18 at 9:45 am: Verbal order for Rectal tube, no physician authentication, time, and date.

Based on observations, record review, and interview staff failed to follow standard precautions for hand hygiene, glove changing, and practice aseptic technique in 2 of 2 patient observations (Pt 2 and 6).

Findings Include:

Review of policy and procedure titled, "Standard Precautions" last revised April 2013 revealed the following:
-Gloves should be changed and hand hygiene performed when moving from a "dirty task" to a "clean task".
-Gloves do not replace the need for hand washing.

Review of policy and procedure titled, "Hand Hygiene" last revised 1/2018 revealed hand hygiene should be performed at the following times:
-Between patient care activities within the same episode of care
-When moving from high contamination patient care activities to cleaner activities
-Between glove changes and after removing gloves after any contact with body fluids, dressings, patient linen
-Before any patient procedure or medication administration

Observations of Patient 6 on 1/11/18 beginning at 11:30 am of revealed Patient 6 was incontinent of a large amount of loose stool covering the vaginal area and buttocks. Registered Nurse F and Certified Nursing Assistant G proceeded to clean Patient 6 with wipes. Registered Nurse F did not thoroughly clean all the stool from outside and inside the vaginal area (labium minus, labium majus). Registered Nurse F then proceeded to change pillow case, apply clean gown to Patient 6, and reposition patient, without changing gloves and performing hand hygiene after performing a "dirty" task then performing a clean task.

On 1/12/18 beginning at 1:20 pm observed Registered Nurse J administer Patient 2's medication and perform wound care. Identified the following infection control issues:

-Registered Nurse J typed on computer keyboard then immediately donned clean gloves without first performing hand hygiene. J then proceeded to open drawers on computer cart and obtain medication vial, J did not clean the rubber septum of the medication vial with alcohol wipe prior to inserting needle to draw up the medication. J then administered the medication via Patient 2's Intravenous line. J did not remove gloves, perform hand hygiene, or don "clean" pair of gloves prior to administering Patient 2's medication.

-Registered Nurse J flushed Patient 2's Intravenous line with normal saline syringe, placed the syringe onto uncleaned tray table, then used same syringe to flush medication through Patient 2's intravenous line.

-Registered Nurse J donned 2 pairs of gloves, removed dressing from Patient 2's leg, flipped through papers to confirm orders, proceeded to clean wound, then removed first pair of gloves and proceeded to apply clean dressing. J did not remove gloves, perform hand hygiene, or don new pair of clean gloves when going from clean to dirty tasks.

-Registered Nurse J reached into "clean" supply box with "dirty" gloves 5 times during wound care observations

-During this observation, Registered Nurse J donned 2 pairs of gloves, cleaned stool off Patient 2, then removed first pair of gloves, and proceeded to apply clean dressing to coccyx wound without first removing "dirty" gloves, performing hand hygiene, or donning "clean" pair of gloves.

Per interview with Chief Nursing Officer B and Director of Quality C on 1/16/17 beginning at 3:00 pm, B and C confirmed staff should not be double gloving as a replacement for hand hygiene, staff should remove all pairs of gloves and perform hand hygiene. Per B nursing staff should clean rubber septum of vial with alcohol wipe before inserting needle.