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Based on record reviews and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient as evidenced by failing to document the cleansing of surgical incisions of 3 (#2, #4, #5) of 3 patients reviewed for cleansing of surgical incisions.
Findings:

Review of the hospital's policy titled "Patient Care Documentation (Nursing)" revealed in part, wound care- explain type of wound, specific care (including supplies and equipment used) and assessment of wound condition in notes/intervention section of shift assessment page.

Patient #2
Review of Patient #2's medical record revealed a standing physician's order for surgical incision care dated 01/06/2022. Surgical Incisions: Daily, and PRN saturation: cleanse with ½ H2O2 and ½ H2O or NS/Alcohol, pat dry, and leave incision open to air. If drainage present, cover with gauze and tape. If staples or TED hose are present, cover with non-stick Telfa. If a copius amount of drainage is present or erythema noted, notify physician. Further review of Patient #2's medical record revealed the nursing staff did not document cleansing of Patient #2's surgical incision as per physician's order on 01/07/2022, 01/09/2022 - 01/13/2022.

Patient #4
Review of Patient #4's medical record revealed a standing physician's order for surgical incision care dated 02/22/2022. Surgical Incisions: Daily, and PRN saturation: cleanse with ½ H2O2 and ½ H2O or NS/Alcohol, pat dry, and leave incision open to air. If drainage present, cover with gauze and tape. If staples or TED hose are present, cover with non-stick Telfa. If a copius amount of drainage is present or erythema noted, notify physician. Further reviewed revealed another physician order dated 02/22/2022 that specified to change lumbar dressing with gauze and tegaderm change QOD (every other day). Further review of Patient #4's medical record revealed the nursing staff did not document cleansing of Patient #4's surgical incision as per physician's orders on 02/22/2022 - 03/02/2022.

Patient #5
Review of Patient #5's medical record revealed a standing physician's order for surgical incision care dated 02/24/2022. Surgical Incisions: Daily, and PRN saturation: cleanse with ½ H2O2 and ½ H2O or NS/Alcohol, pat dry, and leave incision open to air. If drainage present, cover with gauze and tape. If staples or TED hose are present, cover with non-stick Telfa. If a copius amount of drainage is present or erythema noted, notify physician. Further reviewed revealed another physician order dated 02/24/2022 that specified left ankle incision clean with soap and water, island barrier dressing, kerlix, and ace, change daily and PRN (as needed). Further review of Patient #5's medical record revealed the nursing staff did not document cleansing of Patient #5's surgical incision as per physician's orders on 02/27/2022 - 03/02/2022.

In an interview on 03/03/2022 at 4:30 p.m. S1DON verified the nursing staff did not document cleansing of surgical incisions as ordered by physician for Patient #2, Patient #4, and Patient #5.

Based on record review, observation, and interview the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by failing to ensure expired/opened/ and black spots on packages of supplies were not available for patient use.
Findings:

Review of the hospital's policy titled "Stock Rotation" revealed in part, all stock items will be stored using the rotation system and the oldest products will be issued first. This prevents stock deterioration and/or expiration of sterile products.

In an observation on 03/02/2022 at 9:37 a.m. - 10:25 a.m. revealed:
2 of 2 Rusch Mmg Urinary Catheterization system 14FR Coude Catheter with the expiration date of 08/28/2021;
1 Urinary Drainage Bag with anti-reflux device and metal clamp drainage tube package was opened;
1 Tracheostomy clean and care tray noted to have black spots on the bottom of the package; and
1 Non-woven drain sponge 4x4 noted to have black spots on both front and back sides of package.

In an interview on 03/02/2022 at 10:18 a.m. S1DON confirmed the findings of expired/opened/ and blacks spots on packages of supplies found in the clean supply room. S1DON confirmed the above stated supplies should have been discarded.

Based on record review, observation, and interview the hospital failed to ensure the infection prevention and control program, as documented in its policies and procedures, employed methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings. This deficient practice was evidenced by failing to perform hand hygiene when removing dirty gloves and donning clean gloves while performing wound care for 1 (#4) of 1 patients observed for wound care.
Findings:

Review of the hospital's policy titled "Hand Hygiene/Handwashing" revealed in part, indications for hand-washing and hand antisepsis.
4.) Before applying and after removing gloves

In an observation on 03/03/2022 at 1:49 p.m. of Patient #4's wound care performed by S2RN revealed S2RN removed dirty gloves and donned clean gloves 3 times while performing wound care to Patient #4. Further observation revealed S2RN did not conduct hand hygiene when changing her gloves.

In an interview on 03/03/2022 at 2:04 p.m. S2RN confirmed she did not conduct hand hygiene when removing dirty gloves and donning clean gloves while performing wound care on Patient #4.