Every finding on record at Assisteo North Hospice, LLC

Based on observations, interviews, record review, and policy review, the Hospice agency failed to provide wound care in a manner to prevent cross contamination for one of three patients (Patient (P) 1) observed during home visits out of a total sample of 14. This had the potential to increase the risk of infection for the patient. Findings include: Review of P1's "Patient Face Sheet," provided by the agency, indicated that P1 wasadmitted to hospice on 10/16/24 with a diagnosis of sarcopenia. During a home visit on 01/14/26 at 10:45 AM, Registered Nurse (RN) 1 was observed removing P1's soiled pressure sore dressing. RN1 removed his/her gloves and placed a new pair on. Then RN1 cleaned the pressure sore with normal saline; however, afterwards, RN1 did not change his/her gloves. RN1, with the same gloves, checked the depth and tunneling of the pressure sore and RN1 packed a small square of calcium alginate inside the wound bed, placing a protective dressing over the wound. With the same gloves, RN1 assisted in rolling over P1 to his/her back, cleaned an abrasion on P1's left knee. Afterwards, RN1 changed his/her gloves and performed hand hygiene.   During an interview on 01/14/26 at 9:45 AM, RN1 stated that he/she was unaware that he/she needed to change her gloves when going from a dirty area to a clean area. The RN confirmed he/she did not change his/her gloves.   During an interview on 01/14/26 at 11:55 AM, the Administrator confirmed that gloves needed to be changed when going from a dirty area to a clean area. Review of the agency's policy titled, "Infection Control-Hand Hygiene," dated 08/19, indicated, ". . . Procedure: …6. Employees will follow these steps for wearing gloves: …c. Change gloves during patient care if the hands will move from a contaminated body site (e.g. perineal area) to a clean body site (e.g. face). "