Failure to Use Barrier During Wound Care Results in Infection Control Deficiency
Penalty
Summary
A deficiency occurred when staff failed to place a barrier between a resident's foot and the bed linen during wound care treatment, as observed by surveyors. The resident had a history of coronary artery disease, peripheral vascular disease, diabetes mellitus, and a multi-drug-resistant organism (MDRO), and was being treated for two unstageable pressure ulcers on the left foot, one of which was infected. The treatment orders required cleansing, application of betadine, and covering the wounds with dressings, but did not specify the use of a barrier between the wound and bed linen. During the observed wound care procedure, an LPN donned appropriate personal protective equipment and prepared the treatment supplies on a barrier on the treatment cart. However, while performing the wound care, the LPN allowed the resident's left foot, which had open wounds and drainage, to rest directly on the bed linen multiple times without placing a barrier underneath. The LPN acknowledged after the procedure that a barrier should have been used to prevent cross contamination. The DON also confirmed that no barrier was used during the treatment. Additionally, the resident reported that the bed linens were not changed after the wound care procedure, and a CNA confirmed that linens are typically changed once per week, with the resident's linens changed the morning after the observed treatment. Facility policy required the use of standard precautions and enhanced barrier precautions for residents with chronic wounds, and contaminated linen should be bagged at the time of use. The failure to use a barrier and to change potentially contaminated linens was inconsistent with these guidelines.