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Based on observation, interview and record review, the facility failed to ensure staff performed weekly skin assessments for patient's with impaired skin integrity according to the plan of care, updated nursing care plans with individualized interventions, and developed a care plan for dependent edema for 2 (#1, and #7) of 5 patients reviewed for altered skin integrity from a total sample of 15 patients, resulting in the potential for the less than optimal outcomes and delayed wound healing.
Findings include:

--(See A 396)
The facility failed to perform weekly skin assessments according to the plan of care for 2 of 5 patients (#1 and #7).
The facility failed to update a nursing care plan for 1 patient (#1) of 5 patients for turning and repositioning every 2 hours.
The facility failed to develop a care plan for dependent edema for 1 patient (#7) of 5 patients.

Based on observation, interview and record review, the facility failed to follow the plan of care for performing weekly skin assessments for 2 (#1 and #7) of 5 patients; failed to update a nursing care plan with individualized interventions to promote wound healing for 1 (#1) of 5 patients; and failed to develop a care plan for dependent edema for 1 patient (#7) of 5 patients reviewed for altered skin integrity, from a total sample of 15 patients, resulting in the potential less than optimal patient outcomes.
Findings include:

Patient #7
On 7/18/17 at approximately 1115 patient #7 was observed awake in bed. There were 2 family members visiting the patient. The patient's right cheek was observed with multiple abrasions that were red and linear in appearance. The patient's hands were edematous, pale and transparent. There was bruising in various stages of healing noted to the patient's forearms. The patient's hands were resting directing on her bed in a dependent position. When queried a family member explained the patient hands had been swollen since her admission. The family member explained the patient's right cheek abrasions were from when the patient had been intubated. The patient had a tracheostomy (surgical opening in the neck for the placement of a tube for breathing) The patient was able to whisper in response to questions asked by the surveyor. One family member was overheard to say the patient still had a wound on her bottom. When further queried no concerns were voiced by the patient or her visitors.

On 7/18/17 at 1330 a review of the medical record revealed patient #7 was a 68 year old female who was admitted into the facility on 6/27/17 with diagnoses that included ventilator dependent respiratory failure and impaired skin integrity.

A review of the patient's skin assessment dated 6/28/17 revealed the patient had a midline abdominal incision that was clean and dry with steri-strips.
The patient had 2 skin tears to her right upper extremity.
The patient had a partial thickness pressure ulcer (stage 2) to her sacrum that measured 1.0 x 1.0 centimeters (cm). There was a moderate amount of serosanguinous drainage.
The patient had Deep tissue injury to her coccyx that was linear and measured 4.0 cm x 2.5 cm. The area was non-blanchable and was free from drainage.

A review of the patient's skin assessment dated 7/5/17 documented the patient upper right arm skin tears and her midline abdominal incision were healed. The patient's sacral ulcer measured 0.4 cm x 0.4 cm. The patient's coccyx Deep tissue injury measured 3.0 cm x 0.5 cm. The area was non-blanchable and was free from drainage.

Further review of the medical record revealed there were no further skin assessments documented in the clinical record after 7/5/17 (13 days).

A review of the patient's "Impaired Skin Integrity" care plan initiated and dated 6/27/17 documented:
The objective of the care plan: "Patient will demonstrate evidence of pressure ulcer healing."
Interventions: "Assess pressure ulcers each shift...describe the condition of the wound or wound bed-color, odor, presence of necrotic tissue, visibility of bone, muscle, and joints..."
There were no updates or interventions documented on the care plan that addressed the patient's bilateral hand edema on the "Impaired Skin Integrity" care plan.
Additionally, there were no care plans in the medical record to direct or guide the nursing staff with interventions to decrease the presence of edema in the patient's (#7's) bilateral hands or prevent the potential for complications.

On 7/19/17 at approximately 1030 a review of patient #7's medical record was conducted with the facility's wound care nurse team Staff J and Staff K. When queried regarding how often patient skin assessments were performed Staff I said they were done weekly. Staff K was asked to explain why there was no skin assessment performed for patient #7 after 7/5/17, that documented the patient's skin condition, measurements or wound characteristics. Staff K stated, "We don't have any. We got behind. It's late (skin assessment). The patient is scheduled to be seen today. " When asked to explain why there was no care plan for the patient's bilateral hand edema, Staff K said, we were told to only address and assess "open" skin areas. Staff K said edema would not be addressed that would be left up to the floor nursing staff. When asked to explain why there was no care plan for the patient's fluid excess (bilateral hand edema), Staff K offered no further explanation.

Patient #1
On 7/18/17 a 1330 a review of the medical record revealed patient #1 was a 41 year old male who was admitted into the facility on 5/13/17 with diagnoses that included ventilator dependent respiratory failure with hypoxia, sacral ulcer, left ear ulcer, acute kidney injury, diabetes mellitus. The patient was on hemodialysis.

A review of the nursing admission assessment dated 5/13/17 documented the patient was not alert, non-verbal and totally dependent on staff for all activities of daily living.

A review of the patient's "Impaired Skin Integrity" care plan initiated on 5/13/17 documented the following:
Objective: Risk factors for pressure development will be minimized and controlled
There were no interventions documented on the care plan to turn and/or reposition the patient every 2 hours to promote wound healing. The care plan interventions only included: "limit chair sitting to 2 hours at any one time and encourage the patient to shift weight every 15 minutes."

A review of the patient's skin assessment dated 5/15/17 revealed patient #1 had 10 areas of impaired skin integrity that included:
1. An unstageable (full thickness skin loss) sacral pressure sore that measured 9.0 centimeters (cm) x 8 cm.
2. A stage 3 (full thickness skin loss involving damage to or necrosis of subcutaneous tissue) perirectal pressure sore that measured 3.0 cm x 3.5 cm
3. Left ear pressure sore that measured 3.0 cm x 3.0 cm depth obscured by necrosis
4. An occipital unstageable pressure sore that measured 1.0 cm x 1.0 cm
5. Left posterior forearm skin tear
6. Left plantar diabetic ulcer (calloused)
7. Right plantar diabetic ulcer (calloused)
8. Right third metatarsal callous
9. Scrotal edema with soft tissue maceration that measured 3.5 cm x 3.0 cm.
10. Right upper quadrant feeding tube
The patient's Braden score (tool used to predict pressure ulcer risk) of 11 indicated the patient was at high risk for pressure sores. Braden score interventions per protocol included turning the patient every 2 hours.

On 5/17/17 between 0812 and 0825 the patient underwent a debridement of his sacral ulcer due to delayed healing of the pressure sore.

A review of the patient's skin assessment dated 5/19/17 documented the following:
1. Sacral ulcer was a stage 4 (full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures) that measured 9.5 cm x 8.0 cm x 2.0 cm with black eschar and bloody drainage.
2. Perirectal stage 3 ulcer measure 1.5 cm x 3.5 with blood exudate.
3. Left ear measured 2.5 cm x 3.0 cm front and back of ear obscured by necrosis

On 6/1/17 between 0940 and 0950 the patient underwent a debridement of his sacral ulcer due to delayed healing of the pressure sore.

A review of the patient's skin assessment dated 6/9/17 included the following:
1. Sacral ulcer measured 9.5 cm x 8.0 cm x 2.0 cm with undermining 2-4 cm loosely adherent yellow slough
2. Left ear 0.2 x 0.2
3. Penile wound 2.0 x 3.0

Further review of the patient #1's medical record revealed there was no skin assessment performed on the patient after 6/9/17 until 6/20/17 (11 days).

An interview was conducted with Wound Care nurse Staff K. Staff K said she recalled the patient because he had significant wounds. When asked to explain why there was no skin assessment for patient #1 that documented the patient's skin condition, measurements or wound characteristics between 6/9/17 and 6/20/17, Staff K stated, "It was not done. We got behind."

An interview and record review was conducted with the Director of Quality Management Staff M on 7/18/17 at approximately 1430. When asked to explain why the patient's care plan did not include turning and repositioning every 2 hours to promote the healing of the patient's pressure sores. Staff G said his skin care plan included limiting his chair sitting to 2 hours at any one time and encourage the patient to shift weight every 15 minutes. However, Staff G was unable to explain how the patient who was not alert, non-verbal and totally dependent on staff for all activities of daily living could have shifted his own weight every 15 minutes.

On 7/19/17 at 0900 an interview was conducted with the Chief Nursing Officer Staff E regarding patient #1's pressure sores. Staff E explained she was aware of the concern that the patient had pressure sores. She explained the patient had been on a "Specialty Bed" that did not require turning and repositioning every 2 hours. When asked to explain why the patient's "Impaired skin Integrity" care plan was not updated to reflect the patient was on a Specialty bed that did not require turning and repositioning, she stated, "I've reviewed the record. He was turned or repositioned every 2 hours."

On 7/19/17 at approximately 1340 a review of the clinical record was conducted with Staff E and Staff M. Per record review the patient was turned every 2 hours except on the following dates and times:
On 5/16/17 between 0230 and 0704.
On 5/16/17 between 1109 and 1629
On 5/17/17 between 0430 and 0830
On 5/17/17 between 1818 and 2321
On 5/18/17 between 0548 and 1230
On 5/19/17 between 0030 and 0622
On 5/19/17 between 1200 and 1429
On 5/19/17 between 2043 and 2340
On 5/20/17 between 0118 and 0543
On 5/20/17 between 0544 and 0830
On 5/20/17 between 1430 and 1830
On 5/21/17 between 0527 and 0818
On 5/22/17 between 0533 and 1853
On 5/22/17 between 1854 and 0030
On 5/23/17 between 0630 and 1340
On 5/23/17 between 1341 and 1630
On 5/23/17 between 2017 and 0034
On 5/24/17 between 0115 and 0403
On 5/24/17 between 0830 and 1230
On 5/24/17 between 1231 and 1635
On 5/24/17 between 1735 and 0014
On 5/25/17 between 0015 and 0449
On 5/25/17 between 0614 and 1716
On 5/25/17 between 1716 and 2010
On 5/26/17 between 0427 and 0721
On 5/27/17 between 0120 and 0613
On 5/27/17 between 1400 and 1650
On 5/27/17 between 2144 and 0230
On 5/28/17 between 0306 and 0856
On 5/29/17 between 0912 and 1641
On 5/26/17 between 1642 and 2327
On 5/30 /17 between 0216 and 0521
On 5/30/17 between 0522 and 1339
On 5/30/17 between 1340 and 1740
On 5/30/17 between 2015 and 0311
On 5/31/17 between 0311 and 0633
On 5/31/17 between 0836 and 1115
On 5/31/17 between 1116 and 1430
On 5/31/17 between 1431 and 1746
On 5/31/17 between 2030 and 2333
On 6/1/17 between 0430 and 1630
On 6/1/17 between 1631 and 2030
On 6/2/17 between 0030 and 0627
On 6/2/17 between 0800 and 1055
On 6/2/17 between 1056 and 1323
On 6/3/17 between 1140 and 1442
On 6/4/17 between 2320 and 0307
On 6/5/17 between 1137 and 1449
On 6/5/17 between 1137 and 1449
On 6/5/17 between 1736 and 2030
On 6/6/17 between 0630 and 1630
On 6/6/17 between 1724 and 2030
On 6/6/17 between 2031 and 0638 on 6/7/17
On 6/7/17 between 0639 and 1000
On 6/7/17 between 1000 and 1417
On 6/7/17 between 1418 and 0546 on 6/8/17
On 6/8/17 between 0547 and 0830
On 6/8/17 between 0831 and 1801
On 6/8/17 between 2031 and 0558 on 6/9/17
On 6/9/17 between 0605 and 1754
On 6/9/17 between 1755 and 2109
On 6/10/17 between 0155 0608
On 6/10/17 between 0847 and 1540
On 6/10/17 between 1541 and 1850
On 6/10/17 between 1850 and 0537 on 6/11/17
On 6/11/17 between 0830 and 1227
On 6/11/17 between 1228 and 0659 on 6/12/17
On 6/12/17 between 1032 and 1440
On 6/12/17 between 1624 and 2017
On 6/12/17 between 2018 and 0012
On 6/13/17 between 0633 and 1831
On 6/14/17 between 0116 and 0637
On 6/14/17 between 1137 and 1449
On 6/15/17 between 1000 and 1449
On 6/16/17 between 0625 and 0558
On 6/16/17 between 0559 and 1030
On 6/16/17 between 1344 and 1745
On 6/17/17 between 0230 and 0640

There was no further evidence in the medical record that the patient was turned and repositioned every 2 hours after 6/17/17 at 0640. At that time Staff E was overheard and she asked Staff G if she was aware of the actual type of Specialty bed that patient #1 was on. Staff G explained that the order was only for the "Dolphin" bed there were no further specifications documented on the physician's order dated 5/15/17 for the exact type of "Dolphin" bed.

At that time Staff E confirmed that patient was not turned every 2 hours and the care plan for pressure sores should have reflected the need for the patient to be turned and repositioned every 2 hours.

A review of the facility's "Care Planning" policy dated 1/2015 documented:
Policy: The Case Managers will establish a written Plan of Care for each patient which will include a detailed treatment plan. The plan will be updated as required by regulation or with patient need changes.

A review of the facility's "Skin and Wound Assessment" policy, dated 1/22/15 documented:
Procedure: "...3. Wound Care Nurse will be responsible for assessing the wound, making recommendations for treatment plan and taking a photograph of any wound and all wounds along with corresponding measurements...4. Photographs by Wound Care Team will be taken on the initial referral and weekly thereafter. Wound assessments and Braden Scale will be done weekly or if there is a major change in the wound.

A review of the facility's "Skin Integrity and Pressure Ulcer Prevention Plan" policy, dated 1/2015 documented: Roles and Responsibilities of Clinical Staff...2. Licensed Nurse Responsibilities: a) Utilizes Braden Scale assessment to implement and ensure standard.

A review of the undated"Dolphin Care Integrated Bed System" manufacturer's reference printed on 7/19/17 documented: Clinical Indications: "...DolphinCare Fluid Immersion Stimulation technology reduces soft tissue distortion and promotes blood flow, creating a platform that is highly effective for the prevention and healing of pressure ulcers through Stage IV, as well as, treating patients with post-operative flaps and grafts...may also be used for patients whose medical conditions preclude turning and repositioning, or where these interventions may be contraindicated as they place the patient at risk for further compromise, as well, patients with spinal cord injury once the acute injury has be stabilized and these patients have been cleared by a physician. In all cases...clinical indications are guidelines and should be taken only as recommendation for consideration during individual patient assessment by the clinician.

Based on observation, interview and record review, the infection control officer facility failed to ensure nursing staff performed hand hygiene between tasks for 2 of 2 patients (#14 and #15) observed during medication observations out of a total of 15 sampled patients, resulting in the potential for less than optimal outcomes. Findings include:

On 7/19/17 at approximately 1135 while accompanied by the Director of Quality Management Staff M, patient #14 was observed for an insulin injection that was performed by Registered Nurse (RN) Staff U. Staff U was observed as she touched the patient's gown and right lower abdomen with her gloved hands and explained that she would be administering the patient's insulin into her abdomen. The patient was overheard as she said no I don't want it in my stomach. Staff U explained that she would give the patient her insulin into her arm. Staff U proceeded with lifting the patient's gown away from her left upper arm and proceeded with cleaning the patient's arm with an alcohol pad. Staff U injected 4 units of insulin into the patient's left upper outer arm and applied brief gentle pressure. Staff U was observed as she disposed of the used syringe into a wall mounted sharps collection container that was located near the sink in the patient's room.

While wearing the same gloves Staff U was observed as she documented the medication administration via electronic record at the mobile computer work station that was in the patient's room. Staff U did not perform hand hygiene between administering patient #14's insulin injection and documenting the medication administration on the mobile computer work station while wearing the same gloves.

On 7/19/17 at 1145 Staff G was asked if gloves were allowed to be worn while accessing the mobile computer work station. Staff G said she didn't know. She explained that she would obtain the facility's policy.

On 7/19/17 at approximately 1200 while accompanied by the Director of Quality Management Staff G, patient #15 was observed for an intravenous pain medication that was performed by RN Staff V. Staff V was observed as she reached into the patient's gown with her gloved hands and secured the patient's Chest Wall Hep-lock Intravenous (IV) Catheter. Staff V was observed as she cleaned the hub of the heplock with an alcohol pad prior to flushing the catheter with normal saline. Staff V proceeded with administering the intravenous Dilaudid and flushing the IV catheter with normal saline after the Dilaudid was administered. Staff V was observed as she disposed of the used glass syringe and needle into a wall mounted sharps collection container that was located near the sink in the patient's room.

While wearing the same gloves Staff V was observed as she documented the medication administration via electronic record at the mobile computer work station that was in the patient's room. Staff V did not perform hand hygiene between administering patient #15's Dilaudid IV injection and documenting the medication administration on the mobile computer work station while wearing the same gloves.

On 7/19/17 at approximately 1230 a review of the facility's Infection Control policy titled "Standard Precautions" dated 12/2016 documented:
Procedure:
#1. Hand hygiene
A. Perform hand hygiene (soap and water /alcohol based hand gel) upon entering and leaving a patient room. After removing gloves and when indicated after touching any contaminated items or fluids.

On 7/19/17 at approximately 1300 an interview was conducted with the Chief Nursing Officer Staff E regarding the aforementioned concerns. When queried she explained gloves were allowed to be worn by staff while they were working on the computer in the patient's room. She said each patient had a computer designated to them. When asked if it was okay for a nurse to touch a patient's gown and/or body, clean a patient's arm, inject insulin and access an intravenous catheter while wearing the same gloves and proceed with documenting the medication administration into the electronic medical record via the mobile computer work station Staff E said yes. She stated, "If there was no visible blood or blood fluids if would have been acceptable for the nurse's to wear the same gloves." She stated, "That's our policy."

Further review of the facility's Infection Control policy titled "Standard Precautions" dated 12/2016 documented:
#2
Gloves: Are indicated when touching blood, body fluids secretions, excretions and contaminated items.
1. Remove promptly after use and perform hand hygiene.
2. Change between tasks and procedures on the same patient after contact with material that may contain blood and or other body fluids.
3. Change between patients.
4. Do not wear outside patient room unless potential contact with blood or body fluids is anticipated.
5. Gloves may be worn when working on the computer in the patient room.

However, the facility's policy for wearing gloves when working on the computer in the patient room did not specify if contaminated gloves were allowed to be worn when working on the computer in the patients rooms.