Encompass Health Home Health

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, interview, and record review, the agency failed to follow accepted standards of practice to prevent the transmission of infections for 1 of 12 (Patient #4) patients reviewed in that RN E failed to follow the agency’s written policies regarding hand hygiene (cleaning hands) and bag/equipment technique during a visit conducted with Patient #4 on 12/11/24. This failure could have resulted in development of a wound infection for Patient #4 and could result in harm to patients related to infections. The findings included: Record review of the clinical record for Patient #4 included a plan of care, for the certification period of 12/09/24 – 02/06/25, which indicated the patient had a start of care date of 07/03/20 and had diagnoses of encounter for change or removal of non-surgical wound dressing, stage 3 pressure ulcer (a type of wound caused by pressure applied to the skin and underlying tissues in which there is a full thickness loss of skin) to the sacral (tailbone) region, a stage 3 pressure ulcer to the left hip, a stage 3 pressure ulcer to “other site,” and a stage 2 pressure ulcer (a type of pressure ulcer which presents as a shallow crater or blister) to the right buttock, paraplegia (a condition which causes loss of voluntary movement and sensation to the lower part of the body), type 2 diabetes mellitus (a medical condition in which the body cannot regulate the amount of sugar or glucose in the blood which can result in an increased risk of infection and worse outcomes from infections), and surgical removal of both legs above the knee. The plan of care indicated the patient was to receive skilled nurse visits three times a week for eight weeks and then twice a week for one week. Record review of the clinical record for Patient #4 included a physician’s order, dated 12/05/24, which indicated, “… Home Health … M-W-F … Wound treatment as follows … Coccyx [sacral/tailbone area] – Dakins soak [a solution used to clean wounds to treat and prevent infections] x 10 minutes – therahoney [a type of medical grade honey used for wound healing and prevention of infection], aquacel [a type of absorbent wound care dressing], Zetuvit sacral dressing [a type of highly absorbent wound care dressing] … Trochanter [hip/thigh area] – Dakins soak x 10 minutes – Saline [a solution of salt and water] – Prisma [a type of wound dressing used to create a moist environment to assist with wound healing] – Aquacel – Allevyn [a type of absorbent foam wound dressing] … Right Distal [lower] Back – Dakins soak x 10 minutes – Saline – Prisma – Aquacel – Allevyn …Right Medial [middle] Glute [buttock area] – Dakins soak – saline, therahoney, aquacel, Zetuvit … sacral dressing …” During an observation conducted on 12/11/24 at 1:00 p.m., the surveyor observed RN E perform wound care to Patient #4’s wounds. The surveyor observed Patient #4 to be lying in bed with the patient’s laptop at the foot of the bed. The surveyor observed RN E place the clean wound care supplies, including gauze and scissors, directly on top of the patient’s laptop without first placing a clean barrier between the supplies and the surface of the laptop or cleaning the surface of the laptop. The surveyor then observed RN E to pick up the gauze from the surface of the laptop and place the gauze directly onto the patient’s open wounds. The surveyor also observed RN E to pick the scissors up off the laptop and use them to cut a wound care dressing which was then placed directly onto the patient’s open wound. The surveyor also observed RN E remove soiled gauze used to clean the wound secretions from the patient’s wound beds and then reach into a container of clean gauze, without first removing the soiled gloves, cleaning her hands, and placing new gloves onto her hands. The surveyor then observed RN E to remove gauze from the container, place Therahoney on the gauze, and use the gauze to apply Therahoney to the patient’s sacral/coccyx wound while still wearing the soiled gloves and without cleaning her hands. During an interview conducted on 12/11/24 at 1:00 p.m., Patient #4 said that he was receiving antibiotics (a medication used to treat infection) for a wound infection at the time of the visit. During an interview conducted on 12/12/24 at 1:52 p.m., with Physician #1’s Nurse #1, the nurse for Patient #4’s physician, when asked if there was a potential for harm or an adverse outcome to Patient #4 related to the nurse failing to use a clean barrier to place supplies on prior to applying those supplies to the patient’s wounds or to items that would directly touch the supplies that would touch the patient’s wounds or related to the failure of the nurse to remove soiled gloves and clean her hands after touching the wound and before touching clean supplies, Physician #1’s Nurse #1 said, “I would say so.” Physician #1’s Nurse #1 said the clinician would usually place supplies on a clean barrier and said she did not think the patient’s laptop would have been very clean. Physician #1’s Nurse #1 said the patient could contract an infection to the wound related to these failures and said the patient was at high risk for infection to the wounds due to his condition and medical history. During an interview conducted on 12/12/24 at 3:59 p.m., with RN E, when asked what the agency’s policy was regarding using a clean barrier to set supplies/equipment on when providing patient care, RN E said she had not been told to use a clean barrier for patient supplies. When asked why she had set the wound care supplies on the patient’s laptop without cleaning it or putting down a clean barrier first during the visit conducted with Patient #4 on 12/11/24, RN E said her thinking was that it was the patient’s own bacterial flora (germs) so there wasn’t a concern for infection. When asked if it would be important to keep clean supplies on a clean surface when providing wound care to prevent contamination of the supplies, RN E said she would say yes. RN E said it was the agency’s policy and her practice to change gloves and clean her hands after touching a patient’s wound prior to touching clean supplies. When asked about the visit on 12/11/24 with Patient #4 when the surveyor observed RN E to reach into the container of clean supplies with gloves that had been used to touch the patient’s wounds, without changing her gloves and cleaning her hands and replacing her gloves, RN E said she tried to do it the correct way but was human and made mistakes. RN E said the correct process would have been to pull out all the necessary wound care supplies prior to providing wound care and place them on a clean barrier and then after touching the wound to change her gloves and clean her hands and put on clean gloves before touching the clean supplies. RN E said if done that way she would not have to reach back into the container of clean supplies. RN E said the wound to the patient’s right buttock/glute area had areas of necrotic (dead) tissue and the physician had ordered antibiotics for that wound. During an interview conducted on 12/13/24 at 9:44 a.m., the supervising nurse said the agency wanted to make sure there was a clean barrier for clean supplies. When asked if placing the patient’s clean wound care supplies directly on top of a patient’s laptop without first placing a barrier or cleaning the top of the laptop would comply with the agency’s policy and procedure regarding bag/equipment technique, the supervising nurse said that was not in compliance with the agency’s policy. The supervising nurse said the agency’s expectation was that the nurse would keep clean supplies in a clean area. When asked if there were any potential adverse outcomes to the patient related to a failure of the nurse to ensure clean wound care supplies were placed on a clean barrier or in a clean area, the supervising nurse said, yes, there could be a risk of infection. The supervising nurse said the patient was currently being treated for an infection to the wound to the right buttock. When asked if the patient’s history of multiple wounds and wound infections could place the patient at higher risk for developing a new wound infection related to the failure of the nurse to comply with the agency’s infection control policies and procedures, the supervising nurse said, yes. When asked if the nurse should change gloves and wash her hands after touching a soiled surface, such as the patient’s open wound, before touching clean wound care supplies, the supervising nurse said, yes, and said she thought the nurse had not thought the process through thoroughly. The supervising nurse said the nurse should have changed her gloves after touching the soiled gauze, cleaned her hands, and applied new gloves before proceeding to touch clean supplies. When asked if there was a potential adverse outcome to the patient related to the failure of RN E to remove her soiled gloves, clean her hands, and apply new gloves after touching the soiled gauze from the patient’s wounds before touching the clean supplies, the supervising nurse said, yes, there was a risk of infection. The supervising nurse said everyone at the agency was responsible for ensuring the agency’s infection control policies were followed including the clinician (nurse) in the home and the clinical team. During an interview conducted on 12/13/24 at 10:11 a.m., the administrator said it was the agency’s policy and procedure for the nurse to use a clean barrier to place wound care supplies on or to keep clean supplies in a clean area, such as inside the designated clean area of the nurse’s bag, if there was no other clean area available in the home, while providing wound care to a patient. When asked if placing clean wound care supplies directly on top of a patient’s laptop without first placing a clean barrier or cleaning the top of the laptop would comply with the agency’s policy and procedure, the administrator said, no. The administrator said there was a potential risk of infection to the patient related to the failure of the nurse to comply with the agency’s policy regarding bag/equipment technique. The administrator said Patient #4 had a history of chronic wound infections. When asked if the patient’s history of wounds and wound infections could place the patient at a higher risk for developing a new wound infection related to RN E’s failure to comply with the agency’s policies and procedures regarding infection control, the administrator said, yes, especially with the patient’s history. When asked the procedure the nurse should follow after touching a soiled surface, such as a patient’s wound, prior to touching a clean surface, such as clean wound care supplies, the administrator said the nurse should remove the dirty gloves, clean her hands, and then put on clean gloves. When asked if RN E should have removed her soiled gloves, cleaned her hands, and then placed on clean gloves after touching the soiled gauze from Patient #4’s wounds and before touching the clean gauze, the administrator said, yes. The administrator said the administrator, the supervising nurse, the clinician (nurse), and everyone on the clinical team was responsible for ensuring the agency’s infection control policies were followed. Record review of an agency policy titled, “Hand Hygiene,” dated 12-2003, last revised 07/10/24, indicated, “Purpose … To remove dirt and transient pathogenic flora [germs] aiding in the prevention and the spread of infection … Hand hygiene is considered the single most important procedure in the prevention of transmission of infection … It is the policy of the Agency that all field and office personnel will adhere to the Hand Hygiene procedure … At a minimum, personnel will perform hand hygiene in the following instances … After any patient contact … Before and after any glove use … Before handing items in the clean section of the bag … Before and after handling patient care devices … After any contact with patient … or secretions (from wounds …) or with articles contaminated by secretions ...” Record review of an agency policy titled, “Bag/equipment technique,” dated 01-2000, last revised 07/10/24, indicated, “Purpose … To reduce potential cross contamination [the process of transferring germs from one place to another] that may occur through staff/patient contact while providing care … Procedure … Remove a minimum of 2 barriers [an item such as a protective pad placed between a potentially soiled surface and clean supplies] from the bag to be used for clean and dirty fields [areas]. Use paper towels or other barrier such as plastic, under pad, etc., as protective shields for equipment and clean supplies while in the performance of various patient care functions … remove all items needed for the visit. Items are to be placed on the clean barrier … Perform hand hygiene and patient care as applicable.””