Murray Calloway County Hospital Hospice

“Based on observations, interviews, record review, and facility policy review, the hospice agency failed to ensure wound care was performed in a manner to prevent cross-contamination for one of one patient (Patient (P) 13) observed receiving care out of a total sample of 19. Specifically, the facility failed to ensure proper glove usage during wound care, utilize proper disposal of a used brief, and utilize proper hand hygiene when passing medication. Findings included: Review of the Hospice facility policy titled, “Infection Control,” dated February 2023, revealed, “. . . [Hospice] follows organization wide guidelines as appropriate in the Hospice setting for Infection Control . . . The [Hospice] program recognizes that the risk for any Hospice patient acquiring a health care associated infection is dependent on many factors . . .” Review of P13’s undated “Start of Care” page, located on the “Face Sheet” in the electronic medical record (EMR), indicated he/she was admitted to hospice services on 01/09/2025 with a primary diagnosis of Alzheimer’s disease and comorbidities which included a pressure ulcer, stage four (full tissue loss with exposed muscle, tendons, or bone). He/She resided in the inpatient care area of the hospice house where staff provided assistance with wound care and medication administration. Review of P13’s “Plan of Care,” located in the EMR under the “Care Plan” tab and effective 01/13/2025, included, “Mepilex Border Sacrum 9.2 Clean coccyx wound wash topically to cleanse wound, pat dry and apply Flagyl [an antifungal medication] crushed and mixed with petroleum jelly topically for malodorous wound and cover with foam border dressing topically for protection daily . . .” In addition, “Flagyl 500mg [milligrams] apply to wound bed daily and PRN [as needed] for malodorous wound” Start Date 01/13/2025. During an observation on 01/17/2025 at 11:00 AM, Registered Nurse (RN)1 entered the medication room to obtain Flagyl from P13’s medication box in the locked cabinet. RN1 opened the medication bottle and removed one Flagyl 500mg tablet with his/her hands. RN1 did not perform hand hygiene or use gloves to remove the medication before placing the pill into the medication crusher. During an interview on 01/17/2025 at 11:04 AM, RN1 was why he/she did not don gloves before obtaining the medication from the medication bottle. RN1 stated, “I know I did not wear gloves, but I will now.” During an observation on 01/17/2025 at 11:07 AM, RN1 obtained wound care supplies from a cabinet outside P13’s room. RN1 performed hand hygiene and donned gloves. RN1 explained the procedure to P13 via a language translator. RN1 removed the soiled dressing on P13’s coccyx area, then removed her gloves, applied clean gloves without performing hand hygiene. After RN1 provided wound care, she placed a clean dressing over the wound. Without removing his/her gloves and performing hand hygiene, RN1 assisted RN2 and Senior Nurse Aide (SRNA)1 in repositioning the patient and adjusting the pillows. RN1touched the bedside rails with his/her soiled gloves. RN2 removed P13’s used brief and placed it on the floor instead of a trash receptacle while SRNA1 assisted RN1. After RN1, RN2 and SRNA1 finished, they removed their gloves and performed hand hygiene. During an interview on 01/17/2025 at 11:20 AM, RN2 was asked why he/she placed the used brief on the floor instead of a trash receptacle. RN2 stated, “Yes, I did place it on the floor and not in a plastic bag, I know I should have.” During an interview on 01/17/2025 at 11:25 AM, RN1 was asked why he/she did not remove his/her gloves and perform hand hygiene, after providing wound care and before touching the patient’s linens, pillows, and bed rails. RN1 stated, “I did not change gloves, but I know I should have.” RN1 was asked when the last in-service or training on infection control was conducted. RN1 stated, “I don’t remember.” During an interview on 01/17/2025 at 12:40 PM, the Interim Director of Hospice Services was told about the medication and wound care observations. The Interim Director of Hospice Services stated, “My expectation is that gloves are to be changed after providing wound care. The brief should not have been on the floor, and [RN1] should have used a glove to obtain the medication from the pill bottle.” The Interim Director of Hospice Services further stated that he/she had become the Director in September 2024 and did not know if any specific wound care infection control in-services had been done prior.”

“Based on record review and interview, the facility failed to ensure fire drills were conducted quarterly for each shift in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect two (2) of two (2) smoke compartments, staff, and all residents. The facility had the capacity for eight (8) beds with a census of six (6) on the day of the survey. The findings include: Record review, of the facility’s fire drill records for the 12-month period prior to the survey on 01/16/2025 at 1:10 PM, revealed the facility completed the fire drills for first (1st) shift but there were no documented fire drills for the second (2nd) shift for the year 2024. Interview, on 01/16/2025 at 1:11 PM with the Safety Director, revealed the facility was not aware the fire drills were not being conducted for second (2nd) shift. The finding was verified by the Safety Director at the time of record review and the Administrator at the exit conference on 01/16/2025. Actual NFPA Standard: NFPA 101 Life Safety Code, (2012) 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.”