Every finding on record at Bethany Hospice of Western Pennsylvania

Based on review of agency policy and procedure, patient visit observations (OBV) and staff (EMP) interview, the agency failed to to ensure staff followed accepted standards of practice to prevent the transmission of infections and communicable diseases for one (1) of two (2) observations conducted. (Observation 1). Findings include: Review of agency policy/procedure on 9/16/22 at approximately 11:30 a.m. revealed: "Infection Control Policy & Procedure. Subject: Standard Precautions. Effective date: Revised March 2007...Procedure...H...a. Handwashing...Hands must be washed before and after patient contact, after contact with body fluids, immediately after removing gloves...It may be necessary to wash had between tasks on the same patient to prevent cross contamination. Review of agency Bag Technique procedure on 9/16/22 at approximatley 11:45 a.m. revealed: Establish clean area to place bag. Place bag barrier (plastic side down) between surface and bag. Wash hands. Open bag. Place needed equipment outside of bag on clean area... Observation of home visit (Observation 1) conducted on 9/15/22 between approximately 8:30 a.m. and 9:30 a.m. revealed...Skilled nurse (EMP3) entered patient room and placed bag on bedside table. Placed patient dressing supply bag on the bedside table. Moved bag off bedside table and placed it on the chair beside the bedside table. Retrieved equipment from bag. Donned gloves. Obtained patient's vital signs. Removed gloves. Donned new gloves. Performed patient body assessment. Repositioned patient on his side. Removed gloves. Removed supplies from bag and place on bedside table. Opened Dakin's solution bottle. Marked the date on the dressing. Opened supplies. Donned gloves. Applied protective barrier to patient's bilateral inner knees and to left outer ankle. Repositioned patient onto left side. Patient with bowel movement at anal area. Cleansed area and buttocks with wipes. Placed soiled wipes on barrier pad that was on bed. Removed gloves. Donned new gloves. Removed old dressing from left lower buttock (ischial area). Placed old dressing on barrier pad and rolled barrier pad under patient. Removed gloves. Donned new gloves. Applied saline to wound on left lower buttock (ischial area). Wiped area with 4x4 gauze. Removed gloves. Donned new gloves. Wet 2x2 gauze with Dakin's solution, placed in wound. Applied protective barrier to area around wound. Placed Optifoam dressing. Applied attend undergarment. Repositioned patient. Removed soiled attend and pads from under patient. Disposed of supplies. Removed gloves. Cleaned bedside table with Clorox wipes. Cleaned flap on bag and cleaned equipment with Clorox wipes. Donned gloves. Cleaned around patient's eyes with cloth and warm water. Removed trash from the room. Removed gloves. Performed handwashing at the bathroom sink. Removed old oxygen tubing and replaced with new tubing. Returned dressing supply bag to nurse's station. EMP3 donned gloves multiple times during visit with patient and failed to perform hand hygiene between glove changes. Gloves removed and new gloves donned multiple times as nurse moved between patient and equipment. No hand hygiene performed between glove changes during visit. Reviewed findings with EMP3 on 9/16/22 at approximately 9:30 a.m. An exit conference was conducted on 9/16/22 at approximately 1:30 p.m. with the following staff members: facility President/CEO, facility Executive Director, facility VP/Director of Business Development, and the facility Director of Clinical Services. Findings were reviewed.

Based on an observational tour (OBV) and staff (EMP) interview, it was determined that the agency failed to be primarily engaged in providing care and services in a manner that is consistent with accepted standards of practice related to the storage of medical supplies. (Observation 1). Findings include: During an (OBV1) tour of the agency office on 9/13/22 between approximately 10:00 a.m. and 10:30 a.m. the supply room was observed. Observation revealed the following findings: -One (1) box Nitrile sterile gloves with expiration date 8/1/22. -Two (2) Telfa gauze pads with expiration date 11/2020. -Thirty three (33) Petrolatum gauze dressings with expiration date 7/2022. -Five (5) DynaGinate calcium alginate ropes with expiration date 4/2022. -Two (2) Triple Antibiotic ointment boxes with expiration date 8/2022. -Twelve (12) DynaGinate calcium alginate sterile dressing 4x4 with expiration date 1/2022. -Five (5) DynaGinate calcium alginate dressing 2x2 with expiration date 4/2022. -Two (2) DynaGel tubes with expiration date 4/2022. -One (1) DynaGel tube with expiration date 6/2020. -One (1) DynaGel Hydrogel impregnated gauze, sterile with expiration date 4/2022. -One (1) FoamFlex Non-Adhesive Waterproof Foam dressing 4x4 with expiration date 6/2020. -Twenty two (22) FoamFlex Non-Adhesive Waterproof Foam dressing 4x4 with expiration date 4/2022. -One (1) Proximel silicone foam dressing 4x4 with expiration date 6/21/21. -Six (6) Enluxtra wound dressing 6x6 with expiration date 5/2022. -Three (3) Primapore 30cm x 10cm with expiration date 8/2022. A review of the findings was conducted on 9/13/22 at approximately 10:35 a.m. with the agency Executive Director.