Infection Control Lapse During Wound Care
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to maintain infection control during wound care for a resident with multiple diagnoses, including diabetes, dementia, and congestive heart failure. The resident had a physician's order for daily wound care to the right heel, which included cleansing with normal saline, applying Santyl ointment, and covering with a foam dressing. During an observed dressing change, the LPN did not sanitize the over-the-bed table before placing a paper towel and clean dressing supplies on it. The LPN then soaked four-by-four gauze in normal saline and placed it on the paper towel, which allowed the saline to soak through onto the unsanitized table surface. The LPN proceeded to use the now-contaminated gauze to clean the resident's wound, but was stopped by the surveyor. The LPN confirmed during an interview that she had not sanitized the table and acknowledged that the gauze had become contaminated by contact with the unsanitized surface. The facility's policy required clean technique for dressing changes unless otherwise specified by a physician, but this protocol was not followed during the observed wound care event.