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Based on document review and interview, the hospital failed to ensure nursing staff adhered to policies and procedures (P&P) of the hospital and/or physician orders for 3 of 10 patients (P1, P6 and P9).

Findings include:

1. P&P review:
A. Policy titled Negative Pressure Wound Therapy, Revised 01/01/2019, indicated the following: Procedure: Cleanse wound... Dressing Removal/Change and Canister Change: Change dressing every 48-72 hours per physician order... Clean outside surface of pump...

B. Policy titled Hand Hygiene, Revised July 2021, indicated hand hygiene (HH), either with soap and water or alcohol based hand rub, should be performed when any of the following occur: Between patient care activities within same episode of care. When moving from high contamination patient care activities to cleaner activities... Before donning either sterile or non-sterile gloves. Between glove changes and after removing gloves. After any contact with body fluids, dressings, patient linen.

C. Policy titled Wound Assessment "(CIRH)", Revised 04/21, indicated the assessment of a wound will include at a minimum location, size...drainage...and surrounding tissue. Drainage was indicated to be either Serous, Serosanguineous, Seropurulent, or Purulent.

D. Policy titled Central Venous Access Devices (CVAD), Revised 07/01/2021, indicated CVAD catheter site care and dressing changes are performed... Whenever the dressing becomes damp, loosened, or visible soiled.

E. Policy titled Guidelines and Protocols, Clinical; Revised 7/1/21, indicated the following procedures were to be done at the indicated frequencies: Bedfast patients turned. Document position... Every 2 hours. Wounds: Photo documentation and Wound Assessment: Additionally, on admission and at discharge, all abnormal, non-intact, non-healthy skin will be photographed.

2. On 8/16/21, beginning at approximately 3:00 PM, during facility tour and wound care observation, the following was noted:
Patient P1 was in bed for abdominal wound vacuum (vac) dressing changes provided by WCN N1. N1 washed hands, donned gloves, gathered supplies and prepared to begin with the patient's door open to the hallway. A2 went around the bed and closed the door. N1 preceded to remove the transparent occlusive dressing without use of adhesive remover. The patient complained pain, N1 stopped the process, removed his/her gloves, did not perform HH and left the room. Upon return to the room, N1 performed HH, donned new gloves and used adhesive remover to remove the remainder of the occlusive dressing and the sponges covering the wound. N1 laid the used adhesive remover wipes on the patient's sheet. Excoriation type redness was noted at the bottom of the abdominal wound. After removal of the occlusive dressing, N1 removed his/her gloves and applied a new pair without performing HH. A glove tore during application, was removed and a new glove applied without HH. Scissors from the patient's bag of wound care supplies were used to cut strips of sterile occlusive dressing which were applied to the excoriated areas around the wound edges. N1 then opened and cut sterile foam using the same scissors. N1 placed the cut foam onto the open wound for measure, removed it from the wound, re-cut and replaced the foam at least 3 times while touching the underside of the foam (that which had been placed onto/into the open wound area). The cut foam was placed onto the wound. No cleansing/saline wash of the wound was noted. A new transparent occlusive dressing was applied. N1 indicated he/she had an issue with a glove and requested another, A2 handed N1 another glove. N1 removed the glove and applied the new without HH. N1 then, using both hands (one clean glove and one dirty) connected the wound vac tubing to the vac device and pressed the button to start vacuum with the dirty gloved hand. The machine was not cleaned prior to our exit of the room. Following the procedure, the scissors were not cleaned. The dirty scissors were placed on top of the bag of the patient's clean supplies. The scissors and bag of supplies were all handled by N1 with the dirty gloves, moved to the other side of the bed and placed on the patient's sheet to begin change of the second abdominal wound. N1 applied clean gloves without performing HH.

Patient in room 412 (patient P9), was noted to have a mid-line type intravenous catheter with the dressing loose and dangling from the arm.

3. The MR of patient P1, indicated the patient had orders for wound care of the lower right abdominal wound, lower midline abdominal wound, and lower left abdominal wound as follows: NPWT (negative pressure wound therapy) continuous... Every Monday, Wednesday and Friday. The MR lacked documentation of wound care having been provided on Friday 8/13/21 for the lower right abdominal wound, lower midline abdominal wound, and lower left abdominal wound.

The MR of patient P6, lacked documentation of the patient's wounds having been cleaned between 8/5/21 and discharge on 8/10/21. Tracheostomy (trach) documentation, 8/10/21 at 0800 hours indicated the following: Trach/Stoma Site Assessment: Drainage. The record lacked documentation of drainage type/appearance. Wound care management/treatment included the following: 7/15/21 - Apply dimethicone cream to skin PRN (as needed) incontinence 2 times daily, wound location: peri anal. Zinc oxide ointment every 4 hours PRN (as needed) for redness/excoriation on gluteals/coccyx, start 8/4/21. Turn/reposition patient every (q) 2 hours (hrs). The MR indicated the patient had redness/excoriation on gluteals. On 7/16/21 at 2200, the MR indicated moisturizing cream was applied, not moisture barrier. The MR lacked documentation of zinc oxide having been applied to the patient's gluteal wound between 8/4/21 and 8/9/21. The MR lacked documentation of the patient having been turned/repositioned q2hrs as follows: Between 7/29/21 at 2000 hours and 7/30/21 at 0248 hours, the patient was documented in "Semi Fowler's" position. Between 7/30/21 at 0600 hours and 7/31/21 at 0000 hours, the patient was documented in "Semi Fowler's" position. Infectious Disease Progress Note 7/22/21 at 7:13 PM indicated the patient developed an extensive rash involving the upper extremities, lower extremities, chest, abdominal wall, and back... The MR lacked documentation by photography of the rash in the areas as depicted. "LTACH Progress Note" 7/31/21 at 12:16 PM indicated the patient developed wounds under his/her "breast groin area and on skin between the buttocks." The MR lacked photography documentation of the breast wounds. Unable to determine by description if the groin and buttock wounds are those MR photography documentation.

4. In interview on 8/17/21, A2 indicated the nurse of patient P9, re-enforced the dressing and verified it was not changed after found loose.

Based on document review and interview, the hospital failed to ensure nursing staff adhered to policies and procedures (P&P) of the hospital and/or physician orders for 2 of 10 patients (P1 and P6).

Findings include:

1. P&P review:
A. Policy titled Negative Pressure Wound Therapy, Revised 01/01/2019, indicated the following: Procedure: Cleanse wound... Dressing Removal/Change and Canister Change: Change dressing every 48-72 hours per physician order... Clean outside surface of pump...

B. Policy titled Hand Hygiene, Revised July 2021, indicated hand hygiene (HH), either with soap and water or alcohol based hand rub, should be performed when any of the following occur: Between patient care activities within same episode of care. When moving from high contamination patient care activities to cleaner activities... Before donning either sterile of non-sterile gloves. Between glove changes and after removing gloves. After any contact with body fluids, dressings, patient linen.

C. Policy titled Wound Assessment "(CIRH)", Revised 04/21, indicated the assessment of a wound will include at a minimum location, size...drainage...and surrounding tissue. Drainage was indicated to be either Serous, Serosanguineous, Seropurulent, or Purulent.

D. Policy titled Central Venous Access Devices (CVAD), Revised 07/01/2021, indicated CVAD catheter site care and dressing changes are performed... Whenever the dressing becomes damp, loosened, or visible soiled.

E. Policy titled Guidelines and Protocols, Clinical; Revised 7/1/21, indicated the following procedures were to be done at the indicated frequencies: Bedfast patients turned. Document position... Every 2 hours. Wounds: Photo documentation and Wound Assessment: Additionally, on admission and at discharge, all abnormal, non-intact, non-healthy skin will be photographed.

2. On 8/16/21, beginning at approximately 3:00 PM, during facility tour and wound care observation, the following was noted:
Patient P1 was in bed for abdominal wound vacuum (vac) dressing changes provided by WCN N1 in the presence of A2, the other state surveyor and myself. N1 washed hands, donned gloves, gathered supplies and prepared to begin with the patient's door open to the hallway. A2 went around the bed and closed the door. N1 preceded to remove the transparent occlusive dressing without use of adhesive remover. The patient complained pain, N1 stopped the process, removed his/her gloves, did not perform HH and left the room. Upon return to the room, N1 performed HH, donned new gloves and used adhesive remover to remove the remainder of the occlusive dressing and the sponges covering the wound. N1 laid the used adhesive remover wipes on the patient's sheet. Excoriation type redness was noted at the bottom of the abdominal wound. The size of the wound appeared to be approximately 12" (inches) across, approximately 4 1/2" from top to bottom (at highest point) and approximately 0.5" deep. The excoriation appeared to be across approximately 10" of the length of the bottom edge of the wound with a width of approximately 2". After removal of the occlusive dressing, N1 removed his/her gloves and applied a new pair without performing HH. A glove tore during application, was removed and a new glove applied without HH. Scissors from the patient's bag of wound care supplies were used cut strips of sterile occlusive dressing which were applied to the excoriated areas around the wound edges. N1 doffed gloves and donned a new pair with HH. N1 then opened and cut sterile foam using the same scissors. N1 placed the cut foam onto the open wound for measure, removed it from the wound, re-cut and replaced the foam at least 3 times while touching the underside of the foam (that which had been placed onto/into the open wound area). The cut foam was placed onto the wound. No cleansing/saline wash of the wound was noted. A new transparent occlusive dressing was applied. N1 indicated he/she had an issue with a glove and requested another, A2 handed N1 another glove. N1 removed the glove and applied the new without HH. N1 then, using both hands (one clean glove and one dirty) connected the wound vac tubing to the vac device and pressed the button to start vacuum with the dirty gloved hand. The machine was not cleaned prior to our exit of the room. Following the procedure, the scissors were not cleaned. The dirty scissors were placed on top of the bag of the patient's clean supplies. The scissors and bag of supplies were all handled by N1 with the dirty gloves, moved to the other side of the bed and placed on the patient's sheet to begin change of the second abdominal wound. N1 applied clean gloves without performing HH.

Patient in room 412 was noted to have a mid-line type intravenous catheter with the dressing loose and dangling from the arm.

3. The MR of patient P1, indicated the patient had orders for wound care of the lower right abdominal wound, lower midline abdominal wound, and lower left abdominal wound as follows: NPWT (negative pressure wound therapy) continuous... Every Monday, Wednesday and Friday. Between 8/11/21 and 8/16/21, the MR lacked documentation of wound care having been provided on Friday 8/13/21, or days between, for the lower right abdominal wound, lower midline abdominal wound, and lower left abdominal wound.

The MR of patient P6, lacked documentation of the patient's wounds having been cleaned between 8/5/21 and discharge on 8/10/21. Tracheostomy (trach) documentation, 8/10/21 at 0800 hours indicated the following: Trach/Stoma Site Assessment: Drainage. The record lacked documentation of drainage type/appearance. Wound care management/treatment included the following: 7/15/21 - Apply dimethicone cream to skin PRN (as needed) incontinence 2 times daily, wound location: peri anal. Zinc oxide ointment every 4 hours PRN (as needed) for redness/excoriation on gluteals/coccyx, start 8/4/21. Turn/reposition patient every (q) 2 hours (hrs). On 7/16/21 at 2200, the MR indicated moisturizing cream was applied, not moisture barrier. The MR lacked documentation of zinc oxide having been applied to the patient's gluteal wound between 8/4/21 and 8/9/21. The MR lacked documentation of the patient having been turned/repositioned q2hrs as follows: Between 7/29/21 at 2000 hours and 7/30/21 at 0248 hours, the patient was documented in "Semi Fowler's" position. Between 7/30/21 at 0600 hours and 7/31/21 at 0000 hours, the patient was documented in "Semi Fowler's" position. Infectious Disease Progress Note 7/22/21 at 7:13 PM indicated the patient developed an extensive rash involving the upper extremities, lower extremities, chest, abdominal wall, and back... The MR lacked documentation by photography of the rash in the areas as depicted. "LTACH Progress Note" 7/31/21 at 12:16 PM indicated the patient developed wounds under his/her "breast groin area and on skin between the buttocks." "Proper wound care was discussed with the nurse." The MR lacked photography documentation of the breast wounds. Unable to determine by description if the groin and buttock wounds are those MR photography documentation.

4. In interview on 8/17/21, A2 indicated the nurse of the patient in room 412, re-enforced the dressing and verified it was not changed after found loose.