Infection Control Deficiencies in Wound Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during wound care for two residents, leading to deficiencies in infection prevention and control. Resident #53, who had a medical history of senile degeneration, dementia, weight loss, and pressure wounds, was on Enhanced Barrier Precautions (EBP) due to her condition. Despite the presence of signs indicating the need for gown and gloves, Licensed Practical Nurse (LPN) Staff M and Registered Nurse (RN) Staff L only used gloves during wound care, acknowledging afterward that gowns should have been worn as per the EBP policy. Resident #107, who was bedbound and dependent on staff for all activities of daily living, had a surgical wound and a stage 3 pressure injury. During wound care, RN Staff K failed to maintain aseptic technique by using a bottle of wound cleanser that had fallen on the floor, not changing gloves after touching personal items, and not performing hand hygiene between tasks. These actions were contrary to the facility's aseptic dressing change protocol, which requires hand hygiene and glove changes between different stages of wound care. The Director of Nursing and the Regional DON confirmed that the facility's policy required the use of gowns and gloves during wound care under EBP. The Assistant Director of Nursing also acknowledged that using a contaminated bottle of wound cleanser was unacceptable. These lapses in infection control practices placed the residents at risk for potential wound infections, as noted by RN Staff K during an interview.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. Resident #53 and Resident #107 had no negative outcome. B. LPN staff M, RN staff L, RN staff K, and evening supervisor staff B was educated on control and proper change procedure. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Complete Audit of resident with care to ensure appropriate orders and interventions are in place and any abnormal findings was corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: A. License nurses was educated on proper change procedure/technique. B. Competency for change completed on current license nurses and will be completed on any new License nurse hire. Nursing managers to do weekly rounds to ensure appropriate treatment and healing of is followed. Education of staff on the components of F880 this will be provided annually and upon new hire orientation. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will do random audits of care to ensure proper procedure/techniques is being utilized weekly for four weeks then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.