**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility policy and staff interviews, the facility staff failed to follow proper infection control practices regarding a dressing change for 1 sampled resident (#10) and care and services for indwelling catheters to prevent infections for 2 sampled residents (#4 and #6), in a total of 20 sampled residents.
Findings include:
1. For Resident #10, the facility staff failed to conduct a dressing change per facility policy and proper infection control practices to ensure there was no cross contamination and to prevent infection.
Resident #10, was admitted to the facility in 10/2016, with [DIAGNOSES REDACTED]. Review of the facility policy: Wound Dressings: Aseptic, revised 11/30/15 included:
– Gather supplies:
– Gloves (two pairs)
– Prepare label with date and initials
– Gauze – Dressing/Medication/Ointment, as ordered
– Plastic bags.
– Clean over-bed-table.
– Place clean barrier on table and place supplies on the barrier.
– Place a plastic bag for soiled dressing supplies within easy reach.
– Cleanse hands.
– If multiple wounds in close proximity, treat the less contaminated wound first.
– If a break in aseptic technique occurs, stop the procedure, remove gloves, cleanse hands, and apply clean gloves.
– Open dressings without contaminating. Keep the dressing/gauze within the open packet and place it directly on top of the barrier.
– Apply clean gloves and remove the soiled dressing. Discard dressing and gloves. Cleanse hands and apply clean gloves.
– Cleanse or irrigate wound, as ordered.
– Wipe any excess fluid from the surrounding skin using a dry, gauze wipe.
– If gloves become contaminated, remove gloves, cleanse hands, and apply clean gloves.
– Using swab or applicator, apply treatment medication, as ordered.
– Apply and secure clean dressing. Remove gloves and discard.
-Apply prepared label. Cleanse hands.
Review of the 11/2016 Treatment Administration Record (TAR) indicated a Physician’s order of 11/5/16 to cleanse the resident’s left lower shin wound with Normal Saline, and pat dry. Apply [MEDICATION NAME] (cream) to area. Cover with non-adherent abdominal pads, then wrap lightly with Kling (gauze wrap) every day shift.
On 11/30/16 at 10:30 A.M., the surveyor observed Nurse #1 during Resident #10’s dressing change on the anterior lower left shin and lateral aspect of the left shin (two wounds). Nurse #1 cleaned the table and placed a clean towel on the surface. After washing his hands with soap and water, Nurse #1 gathered supplies for the dressing change. He brought in the entire box of gloves, a pair of scissors, a jar of [MEDICATION NAME] (resident specific) wound cleanser and hand sanitizer. When Nurse #1 removed the old dressing from the lower left leg, the surveyor observed that there were two separate wounds. The anterior wound had a copious amount of thick yellow/gray drainage on the old dressing as well as on the wound. The wound bed was grayish in color, with no odor. The wound on the lateral aspect had a moderate amount of serous drainage. Nurse #1 said he forgot to get a bag to dispose of used materials and asked Unit Manager (UM) #1 to get him a bag from the treatment cart. Nurse #1 held the resident’s left heel in one hand and the old dressing in the other hand. UM #1 brought in a Ziploc bag that was not large enough to drop the old supplies into without having to push them in with his hand.
Gloves were changed and hand sanitizer used after wiping off a large amount of drainage with the old dressing. Nurse #1 told UM #1 that he forgot to get the gauze pads to clean the wound. Nurse #1 took over holding up the resident’s left heel (contaminating clean gloves) and asked UM #1 to get the gauze from the Treatment Cart to clean the wound. UM #1 held a newly opened package of 4 x 4 gauze pads and held it out for the nurse. With his contaminated hand, Nurse #1 reached into the clean gauze package and pulled out several clean pads. The whole package was placed on the resident’s bed.
Nurse #1 sprayed the wound cleanser onto the shin wound and patted it dry with gauze. The nurse disposed of the contaminated wad of gauze and pushed it into the bag while still holding some clean gauze in the same hand. Some of the clean gauze touched the inside of the disposable bag. Without changing gloves and cleaning hands, Nurse #1 sprayed the lateral wound with wound cleanser and patted it dry with the leftover gauze in his gloved hand.
While UM #1 held the resident’s leg off the bed, Nurse #1 applied [MEDICATION NAME] Cream first to one wound and then the other, using a new swab each time. The used swabs were placed on the clean table next to clean gloves, Kling wrap and non-adherent dressing pads (). With the same gloved hand, Nurse #1 reached into his uniform pocket to retrieve a pen. He picked up one of the non-adherent dressings with contaminated gloves and initialed and dated it. The non-adherent dressings were approximately 2.0 x 4.0 inches and not the larger abdominal pads as ordered to cover the wounds entirely. Nurse #1 placed the newly contaminated non-adherent dressings over each wound which covered about two thirds of each wound.
After the dressing change, Nurse #1 washed his hands. The contaminated package of gauze pads on the bed were placed into the treatment cart with other patients’ supplies. The surveyor brought this infection control breach to their attention. During an interview on 11/30/16 at 11:30 A.M., (with the Director of Nurses, Nurse Educator, UM #1 and Nurse #1), the Director of Nurses said that Nurse #1 did not follow facility infection control practices and would be re-educated and observed prior to conducting treatments of wounds. After the dressing change, Nurse #1 washed his hands. The contaminated package of gauze pads on the bed were placed into the treatment cart with other patients’ supplies. The surveyor brought this infection control breach to their attention. During an interview on 11/30/16 at 11:30 A.M., (with the Director of Nurses, Nurse Educator, UM #1 and Nurse #1), the Director of Nurses said that Nurse #1 did not follow facility infection control practices and would be re-educated and observed prior to conducting treatments of wounds.
2. For Resident #6, the facility staff failed to ensure the resident’s catheter and tubing were kept off the floor (increasing the risk for infection). Resident #6, was admitted to the facility in 7/2014, with [DIAGNOSES REDACTED]. Review of the resident’s care plan and CNA (Certified Nursing Assistant) care card indicated to keep the catheter bag off the floor. On 11/29/16 at 9:15 A.M., the resident was observed by the surveyor sitting in the dayroom, in the wheelchair. The catheter had a catheter drape cloth over the top, however, the bottom of the catheter bag was resting directly on the floor. On 11/29/16 at 1:35 P.M. and 3:55 P.M., the surveyor observed the resident sitting in the dayroom, in the wheelchair. The catheter bag and tubing were resting directly on the floor underneath the wheelchair. There was no cover on the catheter bag. On 11/30/16 at 6:50 A.M., the surveyor observed the resident lying in bed. The catheter bag and tubing were directly on the floor, next to the resident’s bed. On 11/30/16 at 3:00 P.M., the resident was observed by the surveyor sitting in the wheelchair, in the dayroom. The catheter bag and tubing were resting on the floor. During an interview on 11/30/16 at 3:00 P.M., UM #2 said that the resident has poor positioning in the wheelchair, but was unaware that the catheter bag was on the floor while in bed, as well. UM #2 said that staff inservicing would begin immediately to ensure the catheter bag stays off the floor.
3. For Resident #4, the facility staff failed to ensure that the resident’s catheter bag and tubing were kept off the floor (increasing the risk for infection). Resident #4, was admitted to the facility in 1/2015, with [DIAGNOSES REDACTED]. Review of the indwelling catheter care plan, initiated on 1/28/15, indicated to keep the resident’s catheter bag off the floor. During an observation, on 11/29/16 at 8:50 A.M., the surveyor observed Resident #4 being transported in a wheelchair, down the hallway, by staff, with the Foley catheter bag and tubing dragging on the floor. During an observation, on 11/29/16 at 3:00 P.M., the surveyor observed Resident #4 lying in a low bed, with the Foley catheter bag on the floor. During an observation, on 11/30/16 at 8:45 A.M., the surveyor observed Resident #4 lying in a low bed, with the Foley catheter bag on the floor. During an observation, on 12/1/16 at 7:40 A.M., the surveyor observed Resident #4 lying in a low bed, with the Foley catheter bag on the floor. During an observation on 12/1/16 at 12:30 P.M., with Unit Manager (UM) #1, the surveyor observed Resident #4 lying in a low bed, with the Foley catheter bag on the floor. The surveyor observed UM #1 raise the height of the bed for Resident #4 until the Foley catheter bag was positioned off the floor.
During an interview on 12/1/16 at 12:30 P.M., UM #1 said that Resident #4 is supposed to have a low bed, and that the Foley catheter bag should not be on the floor.