Health inspection·July 10, 2023

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident#1's Wound Physician's note dated 7/7/2023 read in part . Stage 4 Pressure Wound Sacrum .Surgical Excisional Debridement Procedure .Remove Necrotic Tissue . Record review of Resident#1's Physician Orders dated 7/8/2023 read in part . Cleanse wound with wound cleanser or normal saline. Pat dry. Apply Medi Honey (Dressing). Cover with Calcium Alginate (Dressing) and dry dressing as needed for dislodgement or soilage . Observation on 7/10/2023 at 9:04am revealed Resident#1 for pressure ulcer treatment performed by LVN A, resident on his side with urine-soaked linens pushed up alongside Resident#1's back, buttocks and legs. Surveyor noted dressing change performed while resident on soiled linens. Surveyor noted no sanitary area for wound supplies. Surveyor observed clean wound supplies on soiled bedside table with no barrier, and wound cleanser bottle in resident's bed. Surveyor observed LVN A wash and dry hands, apply gloves, remove dressings, remove gloves, don new gloves with no handwashing or hand sanitizer, clean wound, remove gloves, and not wash hands or use hand sanitizer. LVN A donned new gloves and applied new dressings. LVN A did not wash her hands or use hand sanitizer prior to leaving room. In an interview on 7/10/2023 at 9:04am with LVN A, she said she was not certified in wound care and was an agency nurse. She said this was her third time at the facility. She said she had been a nurse for nineteen years and had done wound care in the past, but not consistently. She said she knew about proper handwashing technique and hand sanitizer and she said she had not been performing hand sanitizing. She said she learned about hand washing in nursing school and knew consequences to residents such as infection and prolonged healing if hands are not sanitized. She said the physician was here on Friday and Resident#1 wound was found to be not healing. She said the physician debrided the wound. She said she should have changed the soiled linens before administering wound care. In an interview on 7/10/2023 at 9:30am with the DON, she said they took steps in wound care and the first steps were to assess for pain. She said they should have gathered supplies and placed them on a clean surface like wax paper. She said the wound cleanser is located on the treatment cart and it is applied to 4x4's and taken into the resident's room. She said when dressings were removed the nurse should have removed her gloves, cleaned hands, and reapplied gloves. She said when residents are soiled, incontinent care would be provided prior to wound care to prevent contamination of wound. She said applying hand sanitizer between glove changes is to prevent infection, she said it was policy to do this. In an interview on 7/10/2023 at 12:45pm with LVN B she said she had worked at the facility since November. She said they had done in services last week but could not remember if one of them was on infection control. She said she had been a nurse for 36 years and when residents were soiled, she cleaned them up prior to performing wound care. She said she also placed a barrier under the residents prior to starting wound care. She said when she prepped for the procedure, she cleaned the bedside table and then placed a barrier such as wax paper to put the dressings on and said the reason for this was to prevent infection. She said everything needed to be clean prior to performing the procedure. Record review of facility policy titled, Hand Hygiene, dated 10/24/22, read in part . All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Staff will perform hand hygiene .consistent with accepted standards of practice .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675361 If continuation sheet Page 2 of 2