Improper Wound Care Attempted in Dining Room
Penalty
Summary
The facility failed to maintain proper infection control practices related to wound care for a resident, identified as R47, who was reviewed for wound care. The facility's policy on wound care emphasizes cleanliness and the use of a clean environment for procedures. However, an incident was reported where wound care was attempted in the resident dining room, which is not a clean environment, with other residents present. This action was confirmed by the infection preventionist, who stated that the care was attempted due to the resident's behaviors and refusal of care, although the procedure was not completed due to the resident's undesirable behaviors. Resident R47 has a complex medical history, including chronic venous insufficiency, hypertension with ulcers on both lower extremities, local infections, cellulitis, intellectual disability, schizophrenia, and asymptomatic HIV infection. The resident's physician orders included the application of calcium alginate silver dressing and Santyl ointment to the lower extremities. The incident was brought to attention by another resident, R64, who provided video evidence of the wound care attempt in the dining room and expressed concerns about the unsanitary conditions and potential for infection.
Plan Of Correction
Employee E5 was reeducated on facility treatment policy to align with infection control practices. Residents in the 1st floor dining room were indirectly affected by the cited deficient practice. Residents were assessed by clinical team and do not have any ill effects related to the cited deficient practice. All residents have potential to be affected by deficient practice. The facility infection control risk assessment will be reviewed to monitor for accuracy and will be revised, as needed on or before January 3, 2025. The new IPN will educate all nursing staff on proper wound care treatment and following the facility's infection control policy. Infection Preventionist / designee will conduct visual rounds on both units to monitor that staff are practicing appropriate infection control practices during wound care. Audits will be done weekly x4 weeks then monthly x3 month. Findings will be reported to the QAPI committee.