Failure to Implement Infection Control Practices for EBP and Wound Care
Penalty
Summary
Staff failed to implement proper infection control practices for residents under enhanced barrier precautions (EBP) and during wound care procedures. In one instance, a resident with a feeding tube, who had an order for EBP, was observed being repositioned and receiving a bed bath by staff who wore gloves but did not don required isolation gowns. The resident's medical record indicated multiple complex diagnoses, including stroke, hemiplegia, dysphagia, and a PEG tube, and the facility's policy required both gowns and gloves for high-contact care activities for residents with feeding tubes. Despite this, staff did not follow the policy, as confirmed by the absence of used gowns in the room and acknowledgment from facility leadership. In a separate incident, a wound nurse was observed using the same pair of scissors to remove and apply bandages to a resident's pressure ulcers on both feet without cleaning the scissors between uses. The nurse admitted to not cleaning the scissors between dirty and clean bandages or between different wound sites. The resident involved had significant cognitive impairment and two unhealed Stage 2 pressure ulcers. Facility policy required that multi-use equipment be cleaned and disinfected after each use, but this was not followed, as confirmed by the Director of Nursing.