Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to ensure proper infection control practices during wound care for a resident. The resident, who was cognitively intact and required assistance for care needs, had a diagnosis of left arm hematoma and sepsis. Physician's orders required specific wound care procedures, including cleansing the left arm with normal saline and packing the wound with iodoform. During an observation, an LPN donned a gown and gloves, removed the resident's dressing, and cleansed the area. However, the LPN did not perform hand hygiene after removing her gloves and before donning new ones, which is a critical step in infection control. Additionally, the LPN failed to remove her gloves and perform hand hygiene before repositioning the resident's pillows, further compromising infection control protocols. The Director of Nursing confirmed that the LPN should have washed or sanitized her hands after removing gloves and before donning new ones, as well as before repositioning the resident's pillows. This oversight in following the facility's hand hygiene policy, which emphasizes the importance of hand hygiene in preventing illness, led to the deficiency.
Plan Of Correction
1. Facility provided immediate education to employee who failed to ensure proper infection control practices during wound care. 2. Facility initiated on the spot education to all registered nurses and licensed practical nurses on 4/18/2025 regarding general hand hygiene practices and specific to wound care procedures. Education will be completed by 5/18/2025. 3. Hand hygiene competency, specific to wound care procedures, will be added annual education and competency requirements starting 6/1/2025. 4. Random wound care observation audits will be completed by Director of Nursing or designee once a week for 4 weeks, then monthly for 2 consecutive months. 5. Results of audits will be reported at the Quality Assurance and Performance Improvement meeting.