Infection Control Lapse During Dressing Change
Penalty
Summary
The facility failed to implement proper infection control practices during a dressing change for Resident R84, who was admitted with diagnoses including anemia, cellulitis, and an unstageable pressure ulcer. The facility's policy on Enhanced Barrier Precautions, which was last reviewed on December 3, 2024, mandates enhanced precautions for residents with wounds. However, during an observation of a dressing change, it was noted that the Licensed Practical Nurse (LPN), Employee E24, did not wash her hands for the required 20 seconds and failed to use a barrier to turn off the faucet on four occasions. Additionally, the Nurse Aide, Employee E28, improperly removed her gloves before her gown while doffing personal protective equipment (PPE), contrary to the guidelines provided by the Centers for Disease Control. The facility's hand hygiene procedure, also last reviewed on December 3, 2024, requires staff to perform hand hygiene using proper techniques consistent with accepted standards of practice. Despite these guidelines, the observed practices during the dressing change did not align with the facility's infection control policies, leading to a failure in preventing cross-contamination. This deficiency was confirmed during an interview with the LPN, Employee E24, who acknowledged the lapse in infection control practices during the dressing change for Resident R84.
Plan Of Correction
R84 suffered no ill effects from cited concern. Nursing staff will be educated on proper hand hygiene and doffing of PPE by DON or designee. Hand hygiene and doffing of PPE audits will be conducted weekly x4 weeks then monthly x2 months by DON/designee. There are two staff being observed for hand hygiene/PPE doffing for each audit. There will be one dressing change observed each audit. Audit results will be reviewed through the monthly QAPI process/meeting.