Encompass Health Rehab Hospital of Petersburg

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 36946 Based on observation, staff (EMP) interview, and review of medical records (MR), it was determined nursing staff failed to perform wound care in a manner consistent with infection control policies and procedures in two (2) of two (2) wound care observations (MR9 and MR11). Findings: The surveyor observed EMP3 perform wound care on MR9 at 1:50 PM on June 9, 2025. EMP9 set up clean supplies on a bedside table without cleaning and disinfecting the table and on the patient’s bed. EMP9 removed the old dressing, performed hand hygiene and donned clean gloves. Then EMP3 reached for the patient’s oral suction catheter to give to the patient, went to a storage area in the patient’s room to retrieve a wound measuring tool, obtained measurements of the patient’s wound, input measurements into a shared tablet device, and resumed care of the patient’s wound to include cleaning the wound bed with bone exposed all without changing gloves or performing hand hygiene. The surveyor observed EMP13 perform wound care on MR11 at 9:50 AM on June 10, 2024. EMP13 performed hand hygiene and donned clean gloves. EMP13 removed the soiled dressing, cleansed the wound with wound cleanser, opened the clean dressing and placed the open dressing on a bedside table that had not been previously cleaned and disinfected, and placed the dressing on the wound without performing hand hygiene or changing gloves. An interview was conducted with EMP6 at 10:00 AM on June 10, 2025. EMP6 confirmed gloves should be changed and hand hygiene performed during wound care when moving from contaminated body sites to clean body sites and contaminated gloves should not be worn while touching clean supplies in the patient’s environment. The facility’s policy, Hand Hygiene (last reviewed February 20, 2025) was reviewed and reads in part, “...Indications for hand washing and hand antisepsis...Before and after patient contact, providing care or treatment, and before entering and exiting a patient room or environment...change gloves and perform hand hygiene during patient care if moving from a contaminated body site to a clean body site...””

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 40084 Based on observation, interview and document review, it was determined facility staff failed to follow transmission-based precautions as required in facility policy for a patient with MRSA. The findings include: Review of MR9 revealed the patient had a stage IV pressure ulcer to the sacral area with exposed bone and MRSA (methicillin-resistant staphylococcus aureus, a type of staph infection that is difficult to treat) infection in the wound. MR9 was on contact precautions due to the MRSA infection and was receiving negative pressure wound therapy (a device that applies suction to promote wound healing) with a dressing change three times per week. MR9 was on contact precautions for MRSA of the wound. Facility policy required anyone who entered the patient’s room to wear personal protective equipment (PPE) to include a gown and gloves. During wound care observations on MR9 at 1:50 PM on June 9, 2025, EMP14 came into the room without wearing any PPE. Prior to wound care observations at approximately 1:45 PM on June 9, 2025 EMP15 was observed leaving the patient’s room in PPE to include gloves and gown, not performing hand hygiene, and standing in the hallway with shared vital sign equipment. An interview was conducted with EMP6 at 10:00 AM on June 10, 2025. EMP6 indicated that PPE to include gown and gloves must be worn by anyone entering a patient room on contact isolation and should be removed prior to leaving the patient’s room. The facility’s policy, “Standard and Transmission-Based Precautions” last revised November 13, 2023 was reviewed and reads in part, “...Contact precautions, in addition to standard precautions, will be used for patients known or suspected to be infected with epidemiologically important microorganisms that can be transmitted by direct contact with the patient or indirect contact with environmental surfaces associated with the patient. Wear gloves and/or gowns as patient care tasks dictate in accordance with standard precautions. When direct contact with patient or patient’s environment is anticipated, apply appropriate barrier...” The facility’s policy, Hand Hygiene (last reviewed February 20, 2025) was reviewed and reads in part, “...Indications for hand washing and hand antisepsis...Before and after patient contact, providing care or treatment, and before entering and exiting a patient room or environment...change gloves and perform hand hygiene during patient care if moving from a contaminated body site to a clean body site...””

“IC PROFESSIONAL ADHERENCE TO POLICIES CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (v) The prevention and control of HAIs, including auditing of adherence to infection prevention and control policies and procedures by hospital personnel. This Standard is not met as evidenced by: 40084 Based on observation, interview and document review, it was determined the facility’s infection preventionist failed to conduct audits of adherence to infection prevention and control policies and procedures by hospital personnel. The findings include: The surveyor observed EMP3 perform wound care on MR9 at 1:50 PM on June 9, 2025. EMP9 set up clean supplies on a bedside table without cleaning and disinfecting the table and on the patient’s bed. EMP9 removed the old dressing, performed hand hygiene and donned clean gloves. Then EMP3 reached for the patient’s oral suction catheter to give to the patient, went to a storage area in the patient’s room to retrieve a wound measuring tool, obtained measurements of the patient’s wound, input measurements into a shared tablet device, and resumed care of the patient’s wound to include cleaning the wound bed with bone exposed all without changing gloves or performing hand hygiene. The surveyor observed EMP13 perform wound care on MR11 at 9:50 AM on June 10, 2024. EMP13 performed hand hygiene and donned clean gloves. EMP13 removed the soiled dressing, cleansed the wound with wound cleanser, opened the clean dressing and placed the open dressing on a bedside table that had not been previously cleaned and disinfected, and placed the dressing on the wound without performing hand hygiene or changing gloves. An interview was conducted with EMP6 at 10:00 AM on June 10, 2025. EMP6 indicated that the facility does not currently conduct audits or observations specific to wound care and infection control.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 42042 Based on interviews and document review, it was determined the facility failed to support a safe environment by placing a fully dependent patient with an elevated fall risk in a wheelchair with unlocked arm rest and loose lateral support and neglected to activate ordered wheelchair belt alarm for one (1) of three (3) patients reviewed. The findings include: On 02/13/24 at 10:17 am, the surveyor initiated a review of Patient #1’s medical record with the assistance of Staff Member #1. The History and Physical (H&P) documentation stated that Patient #1 was admitted for intensive rehabilitation therapy services following a stroke and had right-sided hemiparesis (significant weakness on right side per Cleveland Clinic). The patient was determined to be at an elevated fall risk potential as referenced on the interdisciplinary care team (IDT) Plan of Care documentation, “High Risk Precautions”. The admitting physical therapy (PT) evaluation stated that Patient #1 was “wheelchair bound” with a “low” level of physical and cognitive functioning and required “max assist” from staff due to being fully dependent with right-sided “flaccidity” and “decreased sitting balance”. The admitting physician had ordered the patient to have the appropriate self-releasing belt alarm while in wheelchair amongst other fall precautions. A nursing note with date and time of service of 12/26/23 at 2:30 pm by Staff Member #9 indicated a “Post Fall Assessment” which stated in part, “Patient sitting up at nurses’ station in wheelchair, noted leaning toward right side, noted slid to floor from wheelchair, no seatbelt, no armrest noted on wheelchair. Patient expressive aphasic and unable to answer questions asked, patient was sent to... ER via 911”. On 02/13/24 at 3:07 pm, the surveyor met with Staff Member #13 for interview. Staff Member #13 confirmed that following the patient’s fall on 12/26/23, they were consulted to immediately assess the wheelchair. Staff Member #13 stated they had determined that the patient was able to fall from the right side of the wheelchair as the right side arm rest was unlocked, and the right side of lateral support was “loose”. On 02/13/24 at 3:19 pm, Staff Member #1 added that, it was determined that the Posey alarm on the patient’s self-releasing Velcro belt had never sounded as it was never activated. Staff Member #1 confirmed that safety alarms should be tested and verified to be functional and active prior to use according to facility procedures. Staff Member #1 provided the surveyor with the facility Policy #677 titled, “Fall Prevention Program” (with last review date of 08/30/23). On page two (2) of document, the policy stated, in part, “Upon admission, plan of care for fall prevention will be initiated to include at a minimum ...self-releasing alarmed wheelchair belts”. On 02/13/24 at approximately 10:30 am, the surveyor reviewed the Policy #120 titled, “Therapeutic Equipment” (with last review date of 05/25/23) provided by Staff Member #1. The policy stated, in part, “The hospital will maintain medical equipment, facilitate, and monitor staff training, and ensure safe use of medical equipment. Clinicians will be trained prior to equipment use, following manufacturers’ guidelines or general accepted standards of practice...” The same policy continued to state, in part, under “Staff Use of Medical Equipment” section of page two (2), “Staff will follow manufacturer’s guidelines related to safety”, “checks equipment for safety prior to patient use...””