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Based on review of medical records (MR), agency policy and interviews with the staff it was determined the facility failed to ensure the staff measured wounds according to hospital policy and followed physicians orders for all wound care provided.

This affected 1 of 4 medical records (MR) review with wounds and did affect Patient Identifier (PI) # 3, and had the potential to negatively affect all patients served by this facility.

Findings Include:

Policy: Wound Assessment and Documentation
Policy Number: 2
Policy Review Date: 6/4/19

Purpose:

1. To improve patients' skin integrity through timely and consistent clinical practices for assessment and prevention of wounds.

2. To ensure standard documentation related to the assessment of skin and wounds.

Policy:

All patients admitted to the hospital will be screened within 8 hours for risk of skin breakdown and for alterations in skin integrity...

I. Assessment

C. Pressure injuries/ulcers will be staged, measured and photographed in accordance with the wound treatment plan, but no less than weekly.

D. Within 2 days before discharge a final complete assessment is conducted, including descriptions, staging, measuring, and photography as appropriate...

III. Documentation

B. Measurements: Stage 2 and greater pressure injuries, and other wounds as applicable will include the following documentation: Size: Length, Width, and Depth should be recorded in centimeters on admission or discovery, weekly and at discharge.

C. Exudate (drainage): indicate amount, type,color, and odor of exudate.

D. Wound base: State the color, type and proportion of tissue located in the wound base...

E. Wound Edges: Assess and document the presence of new epithelium (i.e. edges rolled and thickened, etc.) Edges may be defined or undefined: attached/unattached rolled edges. Document the location of any undermining or tunneling...

1. PI # 3 was admitted to the facility on 4/26/19 with a diagnosis of Spinal Cord Non-Tramatic and a discharge date of 5/3/19 and the patient was readmitted to the facility on 5/6/19 with an admitting diagnosis of Spinal Cord Injury, Cervical Infusion, End Stage Renal Disease and GI Bleed with Mild Aortic Aneurysm.

Review of the photograph taken of 4/26/19 revealed a small blister to the buttock area measuring 0.5 X 0.3 cm (centimeters).

Review of the photographs taken on 5/2/19 the patient had a skin tear to the left shin which was open to air.

Review of the Prescreening Admission form dated 5/6/19 revealed no documentation of the skin tear or the sacral wound on this admission.

Review of the photographs of the Sacral wound taken on 5/7/19 the patient arrived at the facility with a opened sacral wound radiating to the right buttock area.

Review of the wound section of the MR revealed on 5/7/19 the patient had a skin tear to the left shin. Further review of the MR revealed a photo was taken on this date. The picture revealed the patient had steri strips to the skin tear.

Review of the pictures taken on 5/7/19 of the sacral area revealed the staff used a paper ruler for identification and failed to provide the wound measurements on the ruler. The wound was open and the surrounding tissue to the sacral area and buttocks dark in color.

Review of the wound section within the medical record revealed no documentation the sacral wound was staged nor were wound measurements documented.

Review of the documentation in the wound section of the MR revealed on 5/7/1. there was no documentation of the description of the wound, wound measurements or wound care.

Review of the physician order dated 5/8/19 revealed an order for the left shin as follows: Dry, Daily, Leave left shin OTA (open to air) unless draining. Apply dry dressing.

Review of the MR and all physician orders revealed no documentation a physicians order was written for the steri strips.

The physician order dated 5/8/19 at 9:00 AM revealed the sacral area wound is to be cleansed with wound cleanser and apply foam.Wound care to be performed daily and a low air loss mattress was ordered.

Review of the documentation of the sacral area wound on 5/8/19 revealed the wound was present on admission, there was no undermining, no tunneling, odor or signs of infection and the dressing change was complete. Further review revealed no documentation of measurements or the stage of the wound.

Review of the wound documentation dated 5/9/19 revealed a dressing change was completed and no measurements of the sacral wound or staging of the wound. Further review revealed at 7:30 PM the dressing was dry and intact.

Review of the wound section of the MR dated 5/10/19 revealed the wound had no signs of infection and no exudate. At 8:40 PM the dressing was dry, foam and intact and at 9:11 PM the dressing was also dry and intact. Further review revealed no documentation of wound measurements or the stage of the wound.

Review of the wound section of the MR revealed on 5/11/19 during the 7:00 AM to the 7:00 PM shift revealed no documentation wound care had been performed. Review of the documentation at 8:40 PM the dressing was dry and intact. Further review revealed at 9:11 PM the dressing was dry and intact and no documentation of wound care provided.

Review of the photo dated 5/11/19 revealed the sacral area wound had increased in size and had deteriorated. Further review revealed no documentation of the wound measurements or the time the photo had been taken.

Review of the wound section of the MR revealed on 5/13/19 the dressing was dry and intact and there was no documentation of wound care provided or wound measurements.

Review of the discharge summary dated 5/13/19 revealed the patient was being discharged home with home health and hospice most likely per CM (case manager).

An interview was conducted on 6/20/19 at 3:15 PM with Employee Identifier (EI) # 1, Director of Quality and EI # 2, Chief Executive Officer, who confirm the above mentioned findings.

Based on observations, review of CDC guidelines, facility policy and interviews, it was determined the staff failed to perform hand hygiene per policy.

This affected unsampled patient # 1 and unsampled patient #2 and had the potential to negatively affect all patients served by the facility.

Findings include:

CDC Guidelines to Hand Hygiene Volume 51, Published 2002

Recommendations

"1. Indications for handwashing and hand antisepsis

...G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled.

H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care.

I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.

J. Decontaminate hands after removing gloves ..."

Policy: Hand Hygiene
Policy Number: 170
Policy Review Date: 3/5/2019

Purpose:

To decrease the risk of transmission of infection by appropriate hand hygiene.

Policy:

Every employee will use proper hand hygiene and hand washing techniques.

Indications For Handwashing and Hand Antisepsis

Before and after patient contact, providing care or treatment, and before entering and exiting a patient room or environment.

Wash hands after removing gloves...

Other aspects of hand hygiene:

4. Change gloves and perform hand hygiene during patient care if moving from a contaminated body site to a clean body site.

1. An observation of wound care was conducted on 6/19/19 at 8:35 AM with Employee Identifier (EI) # 3, Wound Care Coordinator, Registered Nurse to observe wound care provided to unsampled patient # 2.

During the observation with EI # 3 after cleaning the wound to the left and right gluteal fold EI # 3 removed gloves and donned clean gloves and failed to sanitize hands prior to donning the gloves. EI # 3 then applied barrier cream to the buttocks, removed gloves and donned clean gloves and failed to sanitize hands prior to donning the clean gloves.

An interview was conducted on 6/19/19 at 9:10 AM with EI # 1, Director of Quality, who confirmed the above mentioned findings.

2. An observation of wound care was conducted on 6/19/19 at 9:15 AM with Employee Identifier (EI) # 4, Certified Rehabilitation Registered Nurse, to observe wound care provided to unsampled patient # 1.

During the observation after removing gloves EI # 4 obtained a disposable pad from the closet and placed under the patient's feet. EI # 4 donned clean gloves and failed to sanitize hands prior to donning the gloves.

An interview was conducted on 6/19/19 at 9:35 AM with EI # 1 who confirmed the above mentioned findings.