Infection Control Lapse During Dressing Change
Penalty
Summary
The facility failed to implement proper infection control practices during a dressing change for Resident R81, as observed by surveyors. The facility's policy for 'Clean Dry Dressing Change' requires hand hygiene to be performed between glove changes to prevent cross-contamination. However, during the dressing change observation, RN Employee E7 did not perform hand hygiene after removing gloves and before donning a new pair of gloves on multiple occasions. This lapse in protocol occurred while changing the dressing on Resident R81's sacral wound, which was ordered to be cleansed with soap and water, followed by the application of an absorbent dressing. Resident R81, who was admitted to the facility with diagnoses including high blood pressure, wound infection, and sepsis, had a documented Stage 4 pressure ulcer. The failure to adhere to infection control practices was confirmed by RN Employee E7 during an interview, acknowledging the omission of hand hygiene between glove changes. This deficiency highlights a breach in the facility's infection prevention and control program, as outlined in their policies and federal regulations.
Plan Of Correction
Resident #81 had no negative outcome from potential cross contamination. Immediate education was provided to the Nurse involved (E7) regarding clean dressing change and hand hygiene. She did not perform any other dressing changes. There were no other issues identified during survey related to dressing changes. To prevent this from happening again, DON/designee educated nursing staff on the clean dry dressing change policy and hand hygiene including donning and doffing of gloves. To monitor and maintain ongoing compliance, the wound nurse/designee will observe 2 dressing changes a week x4, then monthly x2. Negative findings will be corrected. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.