Failure to Follow Proper Infection Control During Wound Care
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program during wound care for one resident with a stage 4 pressure ulcer on the left hip. During an observed wound care procedure, an LPN cleaned the resident's wound while wearing gloves, but then, without removing the soiled gloves or performing hand hygiene, proceeded to apply silver alginate and cover the wound with a border foam dressing. The LPN only removed the soiled gloves and performed hand hygiene after completing the dressing. In interviews, the LPN acknowledged that gloves were soiled after cleaning the wound and confirmed that proper protocol would have been to remove gloves and perform hand hygiene before redressing the wound. The Director of Nursing also confirmed that staff are expected to change gloves and perform hand hygiene after cleaning a wound and before applying new dressings.