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Based on medical record review, observation, and interview, the facility failed to ensure physician's orders for wound care were followed by 1 of 1 (Nurse #1) nurses observed performing wound care.

The findings included:

Medical record review revealed Patient #3 was admitted to the facility on 9/9/2021 for wound care following an extended hospital stay for deep partial and full thickness burns of his right arm, hand, and right lower extremity which required excisions and application of skin grafts on 8/23/2021 and 8/27/2021.

Review of the physician's order for wound care dated 9/13/2021 revealed, "clean right arm, bilateral legs with soap and [water] daily - apply resta to...bilateral thighs daily-apply zeroform to left lower leg, right thigh open area daily-apply silver nitrate soaked kerlix to right lower leg open areas and right knee twice daily-apply kerlix, hydrosorb, ace wrap to bilateral legs daily..."

Observations in Patient #'3 room on 9/9/2021 beginning at 10:36 AM, revealed Nurse #1 removed the wraps and soiled dressings from the patient's bilateral legs. Nurse #1 re-dressed the wounds on the patient's legs. Nurse #1 failed to clean the patient's legs with soap and water after removing the soiled dressings and before she re-dressed the patient's leg wounds.

During an interview on 9/15/2021 at 2:05 PM, the Director of Nursing Clinical Support & Educational Services verified Nurse #1 should have washed Patient's #3's legs with soap and water after removing the wraps and soiled dressings and before applying the new dressings.

Based on policy review, observation, and interview the facility failed to ensure measures to prevent the spread of infectious pathogens were followed when 1 of 5 (Nurse #1) staff members observed providing direct patient care failed to perform hand hygiene between glove use repeatedly.

The findings included:

1. Review of the facility's "Hand Hygiene" policy revealed, "...Perform hand hygiene before...Donning gloves...Performing a clean/aseptic procedure...Handling medication...Perform hand hygiene after...Removing gloves..."

2. Observations in Patient #3's room on 9/15/2021 beginning at 10:36 AM, Revealed Nurse #1 performed hand hygiene, donned gloves, and verified Patient #3's name. Nurse #1 crushed the ordered medications and mixed them in water. Nurse #1 verified placement of the patient's naso-gastric tube (NGT) with an air bolus, flushed the NGT, administered the ordered medications, flushed the NGT, then restarted the enteral feeding pump. (An NGT is a special tube that carries food and medicine to the stomach through the nose.) The nurse repositioned the bedside table, discarded the medication cup, and rinsed the syringe used during the procedure. While still wearing the same gloves, Nurse #1 then administered enoxaparin (Lovenox) subcutaneously into the patient's abdomen and discarded the used syringe into the sharps container. (Enoxaparin is a medication used to prevent the formation of blood clots that is injected under the skin.) Without removing the gloves or performing hand hygiene, Nurse #1 performed incontinence care on the patient and discarded the urine soaked pad into the bio-hazard container. Nurse #1 removed the soiled gloves and donned new gloves without performing hand hygiene. The nurse elevated the patient's bed, gathered the supplies for wound care, removed the wraps and soiled dressings from the patient's right leg, and removed her gloves. Without performing hand hygiene, Nurse #1 donned new gloves and redressed the patient's wounds and re-wrapped the patient's leg. Without removing her gloves and performing hand hygiene, Nurse #1 removed the wraps and soiled dressings from the patient's left leg, performed wound care, and re-wrapped the patient's leg. Nurse #1 then removed her gloves and donned new gloves without performing hand hygiene, repositioned the patient with the assistance of Certified Nursing Assistant #1 (CNA #1) and removed her gloves. Without performing hand hygiene, Nurse #1 donned new gloves, paused the patient's enteral feeding, re-checked the patient's NGT placement using an air bolus, then restarted the patient's enteral feeding pump. Nurse #1 rinsed the syringe, removed her gloves, and performed hand hygiene before leaving the patient's room.

Nurse #1 failed to perform hand hygiene between glove use repeatedly.

During an interview on 9/15/2021 at 1:15 PM, the Director of Nursing Clinical Support & Educational Services was asked when staff should perform hand hygiene. The Director of Nursing Clinical Support & Educational Services stated, "It depends on what they were doing."