Inadequate PPE Use During Wound Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, specifically regarding the use of appropriate personal protective equipment (PPE) during wound care for two residents. The facility's policy mandates the use of enhanced barrier precautions, including gowns and gloves, for residents with conditions such as open wounds or infections that could lead to the transmission of multi-drug-resistant organisms (MDRO). However, during observations, it was noted that the required PPE was not utilized by the staff members providing care. Resident R4, who was admitted with conditions including anemia, stroke, and hemiplegia, was observed receiving wound care without the nurse wearing the necessary gown, only gloves were used. This was despite the resident having an open lesion, which according to the facility's policy, necessitates the use of enhanced barrier precautions. Similarly, Resident R171, who has paraplegia and was being treated for a stage 3 pressure ulcer and a trauma wound, was also observed receiving wound care without the required gown being worn by the attending nurses. Interviews with the staff involved confirmed the oversight, with one nurse acknowledging the requirement for gowns and gloves for both residents. Another nurse incorrectly stated that the wounds did not qualify for enhanced barrier precautions, contradicting the facility's policy. This discrepancy highlights a failure in the implementation of the infection control program, as the staff did not follow the established guidelines for PPE usage during high-contact activities involving residents with open wounds.
Plan Of Correction
Step 1 Resident R4, R171 audited to ensure proper EBP signage (alerting staff of resident needs), bins and PPE available. Step 2 All Residents identified with wounds treatment pass were audited to ensure proper PPE was utilized. Step 3 Wound team educated on EBP protocols and proper PPE to be utilized with wound care. Step 4 Unit Managers/ designee will conduct audits weekly x4, monthly x 2 to per facility protocol. All results will be presented at QA for further review.