Infection Control Lapse During Dressing Change
Penalty
Summary
The facility failed to implement proper infection control practices during a dressing change for a resident, identified as Resident R1. The deficiency was observed when a Registered Nurse (RN), Employee E3, placed a red bag for soiled dressing and treatment supplies on the resident's bed, which is against the facility's infection control policy. Furthermore, the RN did not change gloves or perform hand hygiene after cleansing the wound and before applying Triad cream and a clean dry dressing, which could lead to cross-contamination. Resident R1 had a coccyx wound that required daily cleansing with normal saline, application of Triad cream, and covering with a dry dressing, as per the physician's order. The resident's medical history included diagnoses of protein-calorie malnutrition, knee pain, hypertension, and hyperlipidemia. The failure to adhere to infection control protocols during the dressing change was confirmed by RN Employee E3 during an interview, acknowledging the lapse in proper procedures.
Plan Of Correction
1. R1 was seen by wound consultant and suffered no ill effects from dressing change. 2. Director of nursing immediately educated employee E3 on wound care policy and procedure. 3. Director of Nursing/designee will in-service licensed nurses on policy and procedure for dressing changes. 4. Director of Nursing/designee will audit 3 dressing changes weekly for 2 weeks, then 2 dressing changes weekly for 2 weeks, then 3 dressing changes monthly to ensure compliance with infection control standards during wound care. Audit findings will be shared with QAPI committee.