Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
A deficiency was identified when staff failed to follow infection prevention and control practices during wound care for a resident with a diabetic foot ulcer. Specifically, a licensed nurse entered an Enhanced Barrier Precaution (EBP) room without wearing a gown, donned gloves without performing hand hygiene, and proceeded to open the resident's wound dressing. The nurse acknowledged that both a gown and hand hygiene should have been used prior to the procedure to prevent infection. Further observations revealed that a wound doctor and another licensed nurse also entered the same EBP room to assess the resident's wound without wearing gowns. The wound doctor admitted that the required personal protective equipment (PPE), including a gown and gloves, should have been used in the EBP room. The second nurse confirmed that there were no gowns available by the door or in the medication cart and stated that the use of gown and gloves is necessary to prevent the spread of infection. The facility's infection preventionist confirmed that staff are expected to wash hands or use hand sanitizer before donning gloves and that gowns and gloves are required PPE for EBP rooms. Facility policy indicated that gowns and gloves should be made available immediately near or outside the resident's room and that hand hygiene must be performed prior to donning gloves. These lapses in infection control practices were observed during care for a resident admitted with a diabetic foot ulcer.
Plan Of Correction
04/03/2025 F880 Infection Prevention & Control How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: A.) On 04/01/2025 Licensed Nurse 2 immediately performed hand hygiene. On 04/01/2025 Licensed Nurse 2, Licensed Nurse 3, and Wound Doctor donned enhanced barrier precaution PPE. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: B.) Infection Preventionist completed an audit of staff to ensure no other staff were identified with having the same deficient practice of not performing hand hygiene and donning enhanced barrier precaution PPE. No other areas were identified with having the same deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: C.) Staff have been in serviced 04/01/2025 through 04/04/2025 by Infection Preventionist regarding the importance of hand hygiene and ensuring that enhanced barrier precaution PPE is donned. D.) Infection Preventionist and/or designee will conduct random audits of staff to ensure that hand hygiene is performed and enhanced barrier precaution PPE is donned. All non-compliance issues identified during these audits will be brought forth to the department managers five days a week morning meeting for review, validation, and immediate correction. Administrator will do a trending/analysis and will report quarterly to the QAPI Committee for further evaluation and/or recommendation(s). How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system: E.) Infection Preventionist and/or designee will conduct random audits of staff to ensure hand hygiene is performed and enhanced barrier precaution PPE is donned. All non-compliance issues identified during these audits will be brought forth to the department managers five days a week morning meeting for review, validation, and immediate correction. Administrator will do a trending/analysis and will report quarterly to the QAPI Committee for further evaluation and/or recommendation(s). Include dates when corrective action will be completed. The corrective action completion date must be acceptable to the State: 04/04/2025 Integrated into the quality assurance system: E.) Infection Preventionist and/or designee will conduct random audits of staff to ensure hand hygiene is performed and enhanced barrier precaution PPE is donned. All non-compliance issues identified during these audits will be brought forth to the department managers five days a week morning meeting for review, validation, and immediate correction. Administrator will do a trending/analysis and will report quarterly to the QAPI Committee for further evaluation and/or recommendation(s). Include dates when corrective action will be completed. The corrective action completion date must be acceptable to the State: 04/04/2025