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Based on observations, interviews, and record review the facility failed to provide a sanitary environment to avoid sources and transmission of infections in that:
During wound care for 3 of 3 Patients (Patients #1, #3 and #4), 3 of 3 registered nurses (RNs) (Personnel #5, #11 and #16) did not perform appropriate hand hygiene after removal of soiled gloves; 4 of 4 RNs (Personnel #5, #6, #11 and #16) used the patient's bed side table for a wound care supply field while opened containers of ice water, gastric residual, pudding and applesauce cups were present. The bedside tables were not properly cleaned before or after their use as a wound care supply field, and soiled supplies were placed back on the field along with clean supplies.

Findings included:

Observation on 7/14/14 at 11:35 AM Patient #4 diagnosed with a GI (Gastrointestinal) Bleed, Pneumonitis, Severe Malnutritiion, Dysphagia, Hypertension, and a Stage III Pressure Ulcer received wound care to her sacral pressure ulcer. Personnel #11 placed wound care supplies on top of the patient's bedside table where opened containers of vanilla pudding and applesauce were present. Personnel #11 did not sanitize the bedside table before setting up the field. Personnel #11 removed her gloves several times during Patient #4's wound care but did not sanitize her hands in-between. Personnel #11 placed soiled 4X4 inch gauze onto the clean field that contained clean dressings. After completing wound care to Patient #4's sacrum pressure ulcer, she removed the wound care supplies from the bedside table. She did not sanitize the bedside table before leaving the room.

Observation on 7/14/14 at 11:50 AM revealed Patient #3 diagnosed with Septicemia, Diabetes Type II, Diabetic Neuropathy, Chronic Kidney Disease, Hypothyroidism, Anemia, and Stage II right buttock Pressure Ulcer was positioned on her left side for wound care to a pressure ulcer. Personnel #6 did not sanitize the bedside table or remove an opened container of ice before opening the wound care supply field onto the patient's bedside table. Personnel #6 placed soiled 4X4s onto the field along with clean dressings. After removing the wound care supply field from Patient #3's bedside table she did not sanitize the table before leaving the room.

Observation on 7/15/14 at 10:20 AM revealed Personnel #16 did not sanitize the bedside table before she set up a field for Patient #1's wound care supplies. Patient #1 was diagnosed with ventilator dependent End-Stage Amyotrophic Lateral Sclerosis (ALS), Chronic Respiratory Failure, Urinary Tract Infection, Tracheitis, a Stage IV Left Ischial Pressure Ulcer and shearing to his Right Ischium. Personnel #5 checked Patient #1's G-tube gastric residual which was approximately 60 ml (milliliters) and placed the residual in a container and placed it on a tray next to the wound care supply field on the patient's bedside table. Personnel #5 removed the soiled left ischium dressing. Personnel #16 took the soiled dressing and placed them on the bedside table field. Personnel #5 and #16 removed their gloves and donned cleaned gloves without sanitizing their hands. The bedside table was not sanitized before Personnel #5 and Personnel #16 left the room.

During an interview with Personnel #10 on 7/15/14 at 1:30 PM she confirmed the above observations were breaches in infection control.