THOMASTON, GA- PROVIDENCE HEALTHCARE

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 35062

Based on observation, staff interview, record review, and review of facility policy titled Skin Management Standards, the facility failed to provide wound treatment per the physician’s order and failed to wash/sanitize hands and change gloves during wound treatment for one resident (R) (R67) of three residents reviewed for pressure ulcers. This deficient practice had the potential to place R67 at risk for medical complications and infection.

Findings include:
A review of the undated facility policy titled Skin Management Standards, revealed the procedure for dressing change:
1. Check the doctors’ orders for the type and frequency of dressing and any special instructions required for performing the procedure, including pre-medication for the resident’s comfort.
6. Wash/ Sanitize hands, put on clean gloves, remove soiled dressing, and discard immediately in a plastic bag.
7. Remove gloves, and place them in a plastic bag.
8. Wash/ sanitize hands.
9. Put on a pair of clean gloves.
10. Clean the wound from the center of the wound in a circular motion .
11. Discard gloves.
12. Wash/ sanitize hands.
13. Put on a pair of clean gloves.
14. If ordered, apply medication and topical treatment to the wound.

A review of the Minimum Data Set (MDS) Significant Change assessment dated [DATE] revealed R67 was not able to complete the Brief Interview for Mental Status (BIMS) score assessment, and had diagnoses including neurological condition, paraplegia, and malnutrition. The resident had one stage 4 pressure ulcer that was not present on admission.

A review of the current February 2024 Physician’s Orders revealed the following orders:

1. Sacrum: Clean sacrum with Dakin’s, apply crushed Flagyl 500 milligrams (mg) (a medication used to treat infections) to the wound bed, then apply Dakins 0.5% (a topical antiseptic used to clean infected wounds and ulcers) moistened gauze to wound bed/undermining, super absorbent, cover dry protective dressing such as superabsorbent adhesive – every day shift for Treatment Plan for Sacrum and as needed for misplaced or soiled dressing.
2. Clean Left Elbow, cleanse wound, pat dry, apply Flagyl directly to the wound bed then apply Dakin’s 0.5% moistened gauze to the wound bed, cover with dry protective dressing such as rolled gauze secured with tape or composite. Change Daily/PRN (as needed). Flagyl Oral Tablet 500 mg – Apply to Left Elbow topically every day shift for Treatment to Left Elbow.
3. Left Elbow Medial, cleanse the wound with NS (normal saline) or Dakin’s, pat dry, apply Santyl (an ointment used to remove damaged tissue from chronic skin ulcers) nickel thick to the wound bed, cover with calcium alginate for drainage management, then cover with dry protective dressing such as rolled gauze secured with tape or composite, every day shift for Treatment For medial Elbow and as needed for misplaced or soiled dressing.

Physician Documentation dated 11/28/2023 revealed pressure ulcers to the sacrum, coccyx, heels, and hips- unavoidable.

During observation of wound care on 2/25/2024 at 6:25 am, Licensed Practical Nurse (LPN) BB started treatment to the sacrum. The dressing dated 2/24/2024 was removed. The sacrum wound was cleaned with Dakin’s, and crushed the Flagyl was placed on the Dakin’s soaked gauze which was then placed on the wound bed. LPN BB did not change gloves or sanitize hands after cleaning the wound and before applying the medication. The Dakin’s soaked gauze was not placed into the undermining of the wound. LPN BB completed the treatment, changed gloves, sanitized hands, and moved to the next wound. LPN BB cleaned the left elbow, applied Flagyl to the wound bed, and applied Dakins’ soaked gauze and a dry protective dressing. She then cleaned the medial left elbow with Dakin’s, applied Santyl to the wound bed, and covered it with calcium alginate and a dry protective dressing. The treatments to the left elbow and medial left elbow was performed according to the physician’s order. However, LPN BB failed to change gloves and sanitize
hands after cleaning each wound and between each wound treatment.

An interview with the LPN BB on 2/25/2024 at 7:30 am revealed that she normally sanitizes hands and changes gloves after cleaning and before placing medication and also, she would normally place the Dakin’s soaked gauze into the undermining with a cotton swab. She stated she was nervous.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

33548
Based on observations, staff interviews, and review of facility policies titled Procedure for Washing Pots and Pans, and Proper Temperatures For Meal Preparation and Service, and review of the EcoLab Product Specification document for the Multi-Quat Sanitizer, the facility failed to demonstrate the proper usage of the three-compartment sink to sanitize dishware to prevent contamination, failed to allow dishware items to air dry, and failed to ensure all food items on the steam table were held above 135 degrees Fahrenheit (F) to prevent bacteria growth. These deficient practices had the potential to place residents consuming an oral diet at risk of contracting a foodborne illness. The facility census was 69 with 68 residents receiving an oral diet.

Findings include:
1. A review of the undated facility policy titled Procedure for Washing Pots and Pans, revealed the Procedure section line 3: The third sink sanitizes the items by: a. Use of a chemical sanitizer added to water filling the sink with water; or b. Filling the sink with water kept at 180 degrees F and submerging the items for at least one minute. 4. Place pots and pans on the drain sink to air dry.

A review of the EcoLab Product Specification document for the Multi-Quat Sanitizer stated to expose all surfaces to the sanitizing solution for not less than 1 minute.

Observation on 2/24/2024 at 10:50 am of the Dietary Manager (DM) washing dishware using the
three-compartment sink revealed that the sanitizing sink had not been set up for usage. The DM began to set up the sanitizing sink and was having difficulties getting the sink to fill with sanitizing solution.

Continued observation of the DM revealed that she washed the dishware in soapy water, rinsed it, and placed it in the sanitizing sink that continued to not fill with sanitizing solution. The DM took the plastic hose in the sink that was dispersing the sanitizing solution and splashed it over the dishware. The DM then handed the dishware items to the dietary cook to use, the items were not placed to air dry. Further observation revealed that the facility was using EcoLab brand quaternary sanitizing solution.

During an interview on 2/24/2024 at 10:50 am, the DM confirmed that the dishware was not properly sanitized in the sanitizing solution. The DM confirmed that the facility uses a quaternary sanitizing solution and dishware should be submerged in the solution for at least 60 seconds. The DM was not able to state why the proper procedure was not used and confirmed that she gave the dishware items to the cook to use without air drying.
2. A review of the undated facility policy titled Proper Temperatures for Meal Preparation and Service, revealed the minimum acceptable temperature for meat is 135 degrees F.
Steam table temperatures were completed on 2/24/2024 at 12:35 pm with Dietary Cook AA using the facility’s calibrated thermometer. Continued observation revealed the ground liver had a temperature of 131 degrees F.

During an interview on 2/24/2024 at 12:35 pm, Dietary Cook AA confirmed that after stirring the pan containing ground liver four times the temperature of the meat was 131 degrees F. The Dietary Cook revealed that food items on the steam table should be at least 135 degrees F and the ground liver needed to be re-heated.