Infection Control Deficiency in Wound Care
Penalty
Summary
During a recertification survey, it was found that the facility failed to maintain an effective infection prevention and control program for a resident with a stage three pressure ulcer. The resident, who was cognitively intact, was on Enhanced Barrier Precautions due to a wound. A Licensed Practical Nurse (LPN) did not perform hand hygiene before entering the resident's room and failed to wear gloves while handling a sterile wound dressing. Additionally, the LPN did not change gloves or perform hand hygiene after handling a soiled dressing and before applying a clean dressing to the wound. The facility's policy required that residents with pressure ulcers receive care consistent with professional standards to promote healing and prevent infection. Despite this, the LPN acknowledged not following proper procedures during wound care. The Director of Nursing confirmed that there were missed opportunities to prevent contamination of the resident's wound, as the LPN should have worn gloves while handling sterile supplies and should have changed gloves and performed hand hygiene between handling soiled and clean dressings.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 Corrective action for the affected residents: The nurse was immediately reeducated on proper infection control techniques as it pertains to dressing changes/wound care. Identification of potentially affected residents: All residents with wounds have the risk of being affected by the deficiency. All residents were assessed, and no identification of wound infections were identified as a result of the deficient practice. Measures to prevent reoccurrence: Education will be provided to all licensed staff to ensure that appropriate infection control techniques are practiced with wound dressings/wound care. This will include review of the facility policy, Dressing, clean, incision Policy. Continued compliance: The facility staff will complete auditing for compliance. Skill observations will be completed 2 times per week for 30 days and then 4 times per month ensuring appropriate infection control techniques are followed during dressing changes/wound care. Results of auditing will be brought to the QA meeting. Audits will continue in place until substantial compliance has been achieved as determined by the QA Committee. DON is responsible for compliance.