Infection Control Deficiencies in Wound Care, PPE Handling, and Surveillance
Penalty
Summary
The facility failed to ensure proper infection control practices during wound care for two residents. In both cases, the wound care nurse did not re-clean the wound area after the residents were repositioned onto potentially contaminated linens before applying new dressings. Additionally, privacy was not maintained during wound care, as privacy curtains and window blinds were left open, exposing residents to view from outside or from roommates. The nurse acknowledged not following proper wound cleaning procedures after repositioning the residents. Another incident involved an LPN who did not follow correct procedures for handling and disposing of used personal protective equipment (PPE). The LPN transported soiled, reusable gowns in her ungloved hands and without bagging them, after removing them from the trash can, and carried them down the hall to the laundry room. The LPN also failed to sanitize hands after removing gloves and did not sanitize the treatment tray before returning it to the treatment cart. These actions were observed during wound care for a resident with a sacral wound and a Foley catheter. The facility also failed to conduct required infection surveillance activities. There was no evidence that infection control rates were calculated for three consecutive months, and the infection control policies had not been reviewed annually as required. The Infection Control Preventionist stated she was not trained to calculate infection rates and had not performed this task, and both the Administrator and DON were unaware of when the last policy review or surveillance had occurred.