Failure to Maintain Infection Control During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in infection control practices during wound care for several residents. Staff did not consistently provide a clean location for wound care supplies, with one instance where dressing change supplies were placed on a resident's bedside table among personal food items without cleaning the table or creating a clean field. This was contrary to facility policy, which requires setting up a clean field for wound care supplies. Staff also failed to follow Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols during high-contact care activities. Certified nurse aides (CNAs) assisted with repositioning residents for wound care without donning gowns, as required for high-contact activities involving residents with wounds. In several cases, CNAs and licensed practical nurses (LPNs) did not change gloves or perform hand hygiene between dirty and clean tasks, such as after removing soiled dressings or cleaning wounds and before applying new dressings. One CNA left a resident's bedside during wound care to assist another resident and returned without changing gloves or performing hand hygiene. Interviews with staff confirmed awareness of the required procedures, including the need for gowns during wound care and the importance of hand hygiene after glove removal and between tasks. However, staff acknowledged that these practices were not consistently followed, citing issues such as lack of hand sanitizer or paper towels, but also recognizing that these were not valid reasons to omit hand hygiene. The director of nursing and other clinical leaders confirmed that the observed practices did not meet facility policy or CDC guidelines.