Infection Control Deficiency in Dressing Change Procedure
Penalty
Summary
The facility failed to implement proper infection control practices, as observed during a dressing change for a resident with a stage three pressure ulcer. Employee 9 retrieved a box of medical grade honey from the treatment cart and placed it on an unclean surface, the resident's bedside table, before using it for the dressing change. After completing the dressing change, Employee 9 returned the honey to the treatment cart without cleaning it or labeling it with the resident's name, which is against the facility's infection control policy. The resident involved had multiple diagnoses, including stage two chronic kidney disease, diabetes mellitus type II, and a stage three pressure ulcer. The Director of Nursing confirmed that the facility's expectation was for Employee 9 to label the medical grade honey with the resident's name to prevent its use on other residents. This oversight in infection control practices was identified during a survey, highlighting a deficiency in the facility's adherence to its infection prevention and control program.
Plan Of Correction
1. Medical Grade Honey has been discarded. 2. A comprehensive review of current residents with an order for Medical Grade Honey will be conducted to ensure that it is labeled with resident name. A comprehensive review of current licensed nursing staff will be conducted to ensure that competency for Aseptic Wound techniques was completed. 3. The facility will take further steps to ensure that the problem does not re-occur by in-servicing licensed nursing staff on F Tag 880 with a focus on aseptic wound techniques. 4. Compliance will be monitored by the Director of Nursing/Designee through 5 random audits weekly x 3 weeks, then monthly x 2 months to ensure that Medical Grade Honey has resident name and through 3 random direct observation audits of nurses performing aseptic dressing changes to ensure that nurses are adhering to Aseptic Wound Techniques, with audit results being forwarded to the QAA committee to determine the need for further follow up/monitoring.