Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during the administration of treatment for a resident with pressure ulcers. The resident, who was cognitively intact and required assistance for daily care needs, had a diagnosis that included a left hip fracture, diabetes, and dementia. Physician's orders indicated that the resident's bilateral heels were to be cleansed and dressed every other day due to pressure ulcers. During an observation, a registered nurse provided wound care to the resident's heels without wearing a gown, which was against the facility's policy for enhanced barrier precautions (EBP). The nurse removed the soiled dressing from the resident's left foot, removed her gloves, and donned clean gloves without performing hand hygiene in between. This was confirmed by the nurse during an interview, acknowledging the lapse in hand hygiene. Further interviews revealed that the resident should have been on EBP due to having wounds, but there were no EBP supplies available in the resident's room. The Nursing Home Administrator confirmed that EBP was not in place for the resident and that the nurse should have washed her hands after glove removal and worn a gown during the treatment administration.
Plan Of Correction
Resident 48 had no adverse reactions from Registered Nurse 1's providing wound care without wearing a gown per enhanced barrier precautions (EBP) protocol. Resident 48 has since been discharged in good condition from the facility. Registered Nurse 1 was immediately re-educated on EBP precautions and proper hand hygiene. A facility-wide sweep was conducted of all in-house residents with wounds requiring EBP to ensure EBP is followed during wound/skin treatments. Any issues identified were corrected at the time of discovery. All licensed therapists and nursing staff were re-educated on EBP protocol and proper hand hygiene. The Infection Control Preventionist or Designee will conduct spot-check audits to ensure EBP protocol is being followed along with proper hand hygiene during wound/skin treatments for weekly X4 weeks and monthly X2 months. Identified issues will be addressed at the time of discovery. Audit results are reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education/re-education.