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Based on observation, staff interviews, interviews of family members, and review of facility documents, it was determined the facility failed to ensure proper personal protective equipment (PPE) is worn when entering the rooms of patients on transmission-based precautions (A0749).

Cross Reference:
482.42(a)(2) Infection Control

Based on staff interview, review of facility documents, and review of one of ten medical records (#1), it was determined the facility failed to ensure: 1) patients are turned and repositioned every two hours; and 2) pressure wounds are reassessed weekly by the Wound Care Nurse, in accordance with facility policy.

Findings include:

1) Reference #1: Facility policy titled "Wound Care-Prevention of Skin Breakdown" (revised 8/2020) states, " ... 2. Preventative interventions ... i. Turn every two hours, utilizing a wedge pillow... ."

Reference #2: Facility policy titled "Documentation" (revised 8/2020) states, " ... Frequency of Documentation: Inpatient records require a minimum entry notation once per shift regarding the patient's status, progress and/or changes, ... The content of entries may include notations regarding: ... Comfort and hygiene measures including skin care, positioning, ... ."

On 10/26/23, during review of the medical record of Patient (P)1, in the presence of Staff (S)2, Chief Clinical Officer, the following was revealed:

P1 was admitted on 8/11/23 with an admitting diagnosis of "Acute Respiratory Failure with Hypoxia." Admission documentation from S20 (Registered Nurse) dated 8/11/23 at 6:49 PM indicated P1 was assessed with a "Stage 4 sacral wound and Stage 4 R/L (right and left) ischial wounds."

Review of daily nursing shift notes lacked documentation that P1 was turned and repositioned every two hours, in accordance with facility policy. Upon interview, S2 stated that turning and positioning of the patient should be documented in the nursing note, every shift.

2) Reference: Facility policy titled "Wound Assessment and Documentation"
(revised 8/2020) states, " ...Wounds will be monitored daily and reassessed weekly by the Wound Care Nurse and at the time of any significant change. ... ."

During an interview on 10/26/23 at 1:35 PM, S5 (Wound Care Nurse) stated all patients are seen by a wound care nurse "on admission, then once a week, usually on Thursdays."

Review of the medical record for P1 revealed the patient was admitted on 8/11/23 with an admitting diagnosis of "Acute Respiratory Failure with Hypoxia." Admission documentation from S20 (Registered Nurse) dated 8/11/23 at 6:49 PM, indicated P1 was assessed with a "Stage 4 sacral wound and Stage 4 R/L (right and left) ischial wounds."

Review of the "Initial Wound Care Assessment" for P1, completed by S5, indicated P1's wounds were first assessed by S5 on 8/24/23, 13 days after his/her admission assessment indicated the patient had a Stage 4 sacral wound and Stage 4 right and left ischial wounds.

Review of the "Wound Care Nurse Assessment Log" on 10/26/23 revealed the following:

S5 assessed P1's wounds on 8/31/23 and then again on 9/14/23, 14 days after the previous assessment.

S5 assessed P1's wounds on 9/21/23 and then again on 10/5/23, 14 days after the previous assessment.

On 10/26/23 at 1:45 PM, S5 confirmed the "Wound Care Assessment Log" for P1 lacked documentation of an assessment by a wound care nurse for 9/14/23 and 10/05/23.

Based on observation, staff interviews, and review of facility documents, it was determined the facility failed to ensure proper personal protective equipment (PPE) is worn when entering the rooms of patients on isolation precautions.

Findings include:

Reference: Facility policy titled, "Isolation Precautions" (last revised 12/22) states, " ... It is the policy of [Name of facility] to provide appropriate resources and education to every employee regarding the precautions designed to reduce the risk of transmission of blood-borne pathogens. It is the employee's responsibility to follow these guidelines and to educate patients and visitors. ... C. Contact Precaution ... 2. Personal Protective Equipment (PPE) - Don a gown and gloves as outlined under Standard Precautions ... Remove the gown and gloves before leaving the patient's room and wash hands. ... 3. Signs - A "Contact Precautions" sign will be placed outside the patient's room that specifically indicates the use of hand hygiene and PPE. It may be used in combination with other isolation precaution signs. ... ."

Upon entering the facility on 10/24/23 at 9:30 AM, surveyors were greeted by Staff #1 (Chief Executive Officer). When Staff #1 left to find a workspace for the survey team, two staff members were observed walking into Room #6 and then walking out. A contact isolation sign was posted outside Room #6 indicating the patient was on contact isolation precautions, and a gown and gloves were required when entering the room. Neither of the staff members wore gowns or gloves when entering Room #6. This surveyor did not observe the staff members inside the room, only the individuals entering and exiting the room.

Upon interview at 9:40 AM, Staff #1 stated that the facility's policy indicates that for patients on contact isolation precautions, staff are allowed to cross the patient's room threshold without PPE. He/she stated that per facility policy, staff are permitted to stand three feet inside the doorway of contact isolation rooms. A request was made to Staff #1 for the facility's policy on transmission-based precautions. Review of facility policy titled, "Isolation Precautions" lacked evidence that indicates staff are permitted to enter contact isolation rooms "at least three feet" without first donning PPE.

Upon interview at 10:25 AM, Staff #7 (Respiratory Therapist) confirmed he/she was one of the individuals observed entering Room #6 without wearing PPE. Staff #7 stated, "I went into the room to calm the patient down. The patient was shouting. I did go to the bed and talk to the patient, but I didn't touch the patient. I got caught in the moment." Staff #7 was asked if he/she received training on donning and doffing PPE for patients on isolation precautions. Staff #7 stated, "My training is that you put on PPE prior to going in the room of an isolation patient, but I didn't do that. I should have done that."

Upon interview at 10:59 AM, Staff #11 (RN) confirmed he/she was one of the individuals observed entering Room #6 without wearing PPE. Staff #11 stated, "I went into Room 6 and told the patient I was coming back. I didn't want to ignore [him/her]. The patient likes to shout my name. We are trained to put on PPE prior to going into the room."

A tour of the unit was conducted at 10:10 AM, in the presence of Staff #1 and Staff #3 (Director of Quality and Infection Prevention). The unit is a 25-bed unit with a current census of 15. During a tour of the unit at 10:20 AM, Staff #10 (Patient Care Tech) was observed walking into Room #3 and standing at the foot of the patient's bed while putting on an isolation gown. There was a contact isolation sign posted outside of Room #3 indicating a gown and gloves were required when entering the room. Upon interview, Staff #1 confirmed that Staff #10 should have donned a gown and gloves prior to entering the room.

Upon interview at 11:00 AM, Staff #11 indicated he/she was the nurse for the patient in Room #20. There was a sign outside of Room #20 indicating the patient was on enteric precautions, and that handwashing with soap and water was required. When asked how he/she performs hand hygiene when exiting Room #20, Staff #11 stated he/she was using hand sanitizer when entering and exiting Room #20. Staff #11 was asked if he/she knew the facility's protocol for enteric isolation precautions. Staff #11 stated he/she was not aware of what enteric isolation precautions were.

During a tour of the unit at 2:15 PM, two visitors were observed sitting inside Room #20. Neither visitor was wearing a gown, gloves, or a mask. The sign outside of Room #20 indicated the patient was on enteric isolation precautions. An interview was conducted at 2:19 PM with one of the visitors, who indicated both visitors were family members of the patient. The visitor was asked if he/she was educated by the facility to wear PPE when entering the room. The visitor stated, "Yes they told me, but I don't have to gown. I don't want to wear it. I don't think it's mandatory. I'm a pharmacist - I know when it's mandatory or not." The visitor was asked how he/she performs hand hygiene when leaving the room. He/she stated, "I can use both. I can use the hand sanitizer or the soap and water." None of the staff members observed walking by Room #20 asked the visitors to don PPE.

At 2:20 PM, a visitor was observed inside Room #15 without a gown or gloves. The isolation sign outside of Room #15 indicated the patient was on contact isolation and PPE (gown, gloves, and mask) was required. None of the staff members observed walking by Room #15 asked the visitor to don PPE.

At 2:21 PM, a visitor was observed inside Room #18 without a gown or gloves. The isolation sign outside of Room #18 indicated the patient was on contact isolation and PPE was required. None of the staff members observed walking by Room #18 asked the visitor to don PPE.

Upon interview at 2:22 PM, Staff #3 (Director of Quality and Infection Prevention) was asked who was responsible for educating visitors regarding isolation precautions. He/she stated, "We are all responsible. We should be letting the visitors know that they need to put a gown and gloves on. I'll take care of it."

The "Infection Prevention/Wound Care Meeting Minutes" dated 1/27/23 states, " ... Infection Prevention Surveillance ... Visitors are to be educated on isolation when visiting their loved one to use proper PPE's."