Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during wound care for a resident. On April 9, 2025, an LPN was observed performing wound care on a resident with diagnoses including congestive heart failure and pulmonary edema. The LPN donned a gown, mask, and gloves, and proceeded to clean the resident's wounds on both lower extremities. However, the LPN did not change gloves or wash hands after disposing of the used gauze, which is contrary to the facility's wound care policy that requires handwashing and glove changes between handling dirty and clean surfaces. The resident's care plan indicated potential or actual impairment to skin integrity due to fragile skin and impaired mobility. Despite the physician's order to cleanse the right lower extremity and apply specific dressings, the LPN failed to adhere to proper infection control practices. The Director of Nursing acknowledged that the LPN should have changed gloves and washed hands between handling dirty and clean surfaces during wound care.