| 52 |
BOYINGTON HEALTH AND REHABILITATION |
255092 |
1530 BROAD AVE |
GULFPORT |
MS |
39501 |
2019-03-08 |
686 |
D |
0 |
1 |
M3XR11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, record review, and facility policy review, the facility failed to provide wound care in a manner to promote healing for three (3) of six (6) resident wound care observations: Resident #2, Resident #57, and Resident #133. Findings Include: A review of the facility's policy titled, Pressure Ulcer Treatment, dated (MONTH) (YEAR), revealed that it is the purpose of this facility's procedure to provide guidelines for the treatment of [REDACTED]. The Pressure Ulcer Treatment procedure outlined certain steps in the procedure as follows: Put on exam gloves, loosen tape and remove dressing, remove gloves, then wash hands, and now put on clean gloves. Observe the pressure ulcer, dress the pressure ulcer with the prescribed dressing, discard all disposable items into designated container, and remove gloves and discard into designated container. Wash hands. Resident #2 An observation, on 03/06/2019 at 8:46 AM, revealed Resident #2's wound care was provided by Registered Nurse (RN) #3. RN #3 performed the wound care on three (3) separate pressure wounds: A Stage 4 pressure wound to the left (L) Ischium, a Stage 4 pressure wound to the right (R) Ischium, and a Stage 4 pressure wound to the sacral area. RN # 3 performed the wound care to both of the Stage 4 pressure wounds to the (L) Ischium and (R) Ischium, without incident. During the wound care on the Stage 4 pressure wound to the sacral area, RN #3 discarded the soiled 4X4 gauze used for cleaning the wound, and then continued with the wound care by applying two (2) out of three (3) dressing ropes into the wound bed without changing her gloves and washing her hands. After applying the second dressing rope, it was then that RN #3 removed her gloves, washed her hands, put on new gloves, and then continued to apply the third dressing into the wound. During an interview, on 03/07/2019 at 11:00 AM, Registered Nurse (RN) #3 confirmed she did not wash her hands after she discarded the soiled gauze from cleaning the sacral wound, and before she applied the first two (2) medicated rope dressings. RN #3 stated she remembered washing her hands before she applied the third medicated rope dressing. RN #3 stated, I didn't realize I didn't wash my hands, because I usually wash my hands before and after each time I apply the rope dressing into the wound. RN #3 stated not washing your hands is an infection control concern. A review of Resident #2's Order Summary Report for Active Orders as of 03/08/2019, revealed an order, dated 03/05/19 and start date of 03/06/19, to cleanse wound to sacrum with normal saline, pat dry, apply skin prep to peri-wound. Fill wound with alginate extra rope wound dressing, cover with 4x4 gauze, and cover with super absorbent dry dressing daily and as needed (PRN) every day shift. Review of Resident # 2's Electronic Treatment Administration Record (ETAR), dated (MONTH) 03/01/2019-03/31/2019) 2019, revealed the following treatment been provided for the sacral wound: Cleanse wound to sacrum with Normal Saline (NS) and pat dry, apply skin prep to peri-wound, Fill wound with alginate extra rope wound dressing, cover with four by four (4x4) gauze, and cover with super absorbent dry dressing daily and as needed (PRN) every day shift. During an interview, on 03/07/2019 at 11:15 AM, the Director of Nursing (DON) revealed RN #3 should have washed her hands after she cleaned the sacral wound, and before she applied the medicated rope dressing. The DON stated, If your hands are not washed, that it is an infection control concern. An interview, on 03/07/2019 at 1:54 PM, with Licensed Practical Nurse (LPN) #1/Care Plan Coordinator, revealed it was her expectation that the nurse would provide the wound care treatment, without risking the possible spread of infection. An interview, on 03/07/2019 at 3:32 PM, with Registered Nurse (RN) #2/Infection Control Nurse, said during the wound care provided on Resident #2, RN #3 should have washed her hands after cleaning the wound, and prior to the packing of the wound with the rope dressing. Review of Resident #2's Discharge Minimum Data Set (MDS), dated [DATE], revealed a Basic Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Further review of the MDS revealed Resident #2 was coded for the presence of two (2) Stage 3 pressure wounds. Review of Resident #2's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/19/18, revealed a Basic Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Further review of the MDS revealed Resident #2 was coded for two (2) Stage 4 pressure wounds. Review of the Face Sheet revealed Resident #2 was admitted by the facility on 03/05/2013, and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #57 An Observation, on 03/07/19 at 10:15 AM, revealed Registered Nurse (RN) #3/Wound Care Nurse, performed wound care to resident #57 sacrum with the assistance of Certified Nursing Assistant (CNA) #3. RN #3 placed a red bag on resident's bed to the right side of the resident's right leg. RN #3 removed the old dressing and discarded the dressing in the red bag. RN #3 washed her hands, gloved, and began to clean the wound. RN #3 cleaned the wound, and patted it dry. RN #3 applied Santyl to the wound bed with a Q-tip applicator, and covered the wound with a silicone dressing. RN #3 wore the same gloves that she had on while cleaning the wound to apply the Santyl and clean dressing to the wound. RN #3 failed to remove her gloves, wash her hands, and re-glove after cleaning the wound and before applying the Santyl and the clean dressing to the wound. During an interview, on 03/07/19 at 10:48 AM, RN #3/Wound Care Nurse, stated, I knew what I did when I did it. I didn't change gloves and wash my hands after cleaning the wound and before I applied the Santyl and the clean dressing. It could be an infection control issue. Review of Resident #57's Electronic Treatment Administration Record (ETAR), dated (MONTH) 2019, revealed the daily wound care treatment to the sacrum was provided daily as follows:. Clean sacrum with Normal Saline (N/S), Pat dry, and apply Santyl in a thin layer. Pack with gauze and cover with silicone dressing daily and PRN. An interview, on 03/07/19 at 3:22 PM, with RN #2/ Infection control nurse, revealed, RN #3 should have removed her gloves, washed hands and re-gloved before placing the Santyl and bandage on the clean wound. I see that as an infection control Issue. An interview, on 03/07/19 at 3:44 PM, with the Director of Nursing (DON) revealed, the nurse not changing her gloves and washing her hands after cleaning the wound and before applying Santyl and the dressing is an infection control issue. Review of Resident #57's Significant Change MDS, with an ARD of 01/11/19, revealed a BIMS score of 10, which indicated moderate cognitive impairment. Further review of the MDS revealed Resident #57 was coded for an unstageable wound. Resident #133 An observation, on 03/05/19, 4:40 PM, revealed Registered Nurse (RN) #3/Wound Care Nurse provided Resident #133's wound care to the right foot/great toe. RN #3 was assisted by Certified Nursing Assistant (CNA) #3. RN #3 set up the wound care supplies on the over bed table, and then she placed the red biohazard bag on Resident #3, which positioned the right toe wound between RN #3 and the red biohazard bag. After looking over the supplies RN #3 identified she forgot to get scissors from the wound care cart. RN #3 left the room, and returned with the scissors in her bare hands. RN #3 laid the scissors on the tray containing her clean dressings without cleaning the scissors. RN #3 removed the dirty dressing, and discarded it into the red biohazard bag. RN #3 washed her hands and gloved to begin cleaning the wound. RN #3 wiped the wound with normal saline soaked gauze, and discarded the gauze into the red bag. RN #3 got another piece of normal saline gauze, wiped the other side of the wound, and discarded the gauze into the red bag. RN #3 took another piece of the normal saline gauze, wiped the wound, and the normal saline dripped down the side of the foot. RN #3 took the same piece of gauze and reached down to catch the dripping saline and wiped back towards the cleaned wound going from an uncleaned area to a cleaned area, thus wiping dirty to clean. RN #3 did not reclean the wound before attempting to apply the wound vac to the wound. RN #3 washed her hands and gloved, and then picked up the foam that was to be packed into the wound and crossed the cleaned wound over to the red bag and held the foam above the red bag, with the dirty dressing and gauze in it, and began trimming the foam with the uncleaned scissors. RN #3 brought the foam from over the red bag back to the wound, and placed it on the wound. She then reached back over and got the second piece of foam and crossed the clean wound again going to the red bag. RN #3 began trimming the foam over the red bag, and then brought the foam back and placed it on wound. She picked up the end of the wound vac that was to be placed over the foam on the wound. RN #3 placed the wound vac tubing on Resident #133's gown. The end to the tubing was uncapped. RN #3 sealed the part of the wound vac with the dressings cut earlier. She then picked up the tubing from the gown and hooked it to the wound vac itself without cleaning the uncapped tube. Suction was obtained. RN #3 cleaned up her trash, washed her hands, and exited the room. An interview, on 03/05/19 at 5:10 PM, with RN #3/Wound Care Nurse revealed, I did wipe the wound from dirty to clean and I knew it when I did it. RN #3 stated, I didn't think about crossing over the wound to the red bag with the foam then bringing it back over and putting it in the wound. I can see where that would be a contamination issue. I cleaned the scissors before bringing them in the room, but I didn't reclean them after bringing them into the room in my hand. I didn't think about that being an issue but I can see where they could be considered dirty being toted in my bare hand. I held the foam above the red bag to trim it, and I wasn't thinking about it being a contamination issue since I didn't touch it. But with the dirty dressing being in the red bag I can see it being a issue. Record review of Resident #133's Physician order [REDACTED]. 1/2 strength wet to dry packing. Cover with 4x4s and wrap with Kerlix PRN (as needed) when wound vac is reapplied. Start Date 02/27/19. (2) Wound vac (negative pressure wound therapy) in place to wound to right great toe amputation site. Apply wound vac at amputation site at 125 mmHg (millimeters of Mercury) Change Q (every) Tuesday and Friday. Start Date 02/26/19. During an interview, on 03/07/19 3:08 PM, RN #2/Infection Control Nurse, revealed wiping the resident's wound from dirty to clean and not recleaning the wound before dressing it would be a infection control issue. RN #2 said RN #3 should not have crossed the leg with the foam to the red bag. RN #2 stated RN #3 shouldn't go across the wound with the wound vac foam because your crossing the clean wound with supplies coming from the over bed table. RN #2 said RN #3 was going back to the clean wound with something dirty after she held it over the red bag. RN #2 also stated the tubing should not have been laid on Resident #133's gown. It should have been on a clean surface or RN #3 should have cleaned it before connecting it to the other capped end of the tube. RN #2 also stated the scissors should have been recleaned before using them since she had transported them in her bare hand. An interview, on 03/07/19 at 3:49 PM, with the Director of Nursing (DON) revealed RN #3's failure not to reclean the scissors before cutting the clean dressing was an infection control issue. The DON stated RN #3 crossing the clean wound with the foam was an infection control issue also. The DON stated RN #3 holding the foam over the red bag to trim it, and then bringing it back to the wound and packing the wound with the foam was an infection control issue. The DON stated RN #3 laying the uncapped tube of the wound vac suction part placed on top of the wound on the resident's gown and not cleaning it before connecting it to the capped end of the actual wound vac was an infection control issue. The DON stated RN #3 should have cleaned her scissors after having them in her hand and before cutting a clean dressing. Review of the Face Sheet revealed Resident #133 was admitted by the facility, on 02/12/19, with the included [DIAGNOSES REDACTED]. Review of Resident #133's Admission MDS, with an ARD of 02/19/19, revealed a BIMS score of 11, which indicated moderate cognitive impairment. Further review of the MDS revealed Resident #133 was coded for a Stage 2 wound. |
2020-09-01 |