Failure to Follow Infection Control Practices During Wound Care
Penalty
Summary
A deficiency was identified when a registered nurse (RN) failed to follow appropriate infection control practices during wound care for a resident with multiple pressure ulcers. The resident had a history of acute kidney failure, hypertension, osteoarthritis, muscle wasting, and was at risk for impaired skin integrity. The care plan included regular skin assessments, repositioning, and wound treatments as ordered. The resident had two significant wounds: a coccyx pressure ulcer, which had been cultured and found to be infected, and a right gluteal fold wound, both requiring specific dressing changes and infection control measures. During an observed wound care procedure, the RN performed hand hygiene and donned personal protective equipment before removing the dressings from both wounds. However, after removing the old dressings, the RN changed gloves but did not wash her hands. She then cleansed, packed, and dressed both wounds consecutively using the same gloved hands, including using unsterile and sterile gauze on both wounds without changing gloves or performing hand hygiene between wounds. The RN also applied skin prep and dressings to both wounds with the same gloved hands, despite one wound being known to be infected. This process was confirmed by both the RN and the Director of Nursing (DON) as improper and having the potential for cross-contamination between wounds. The facility's wound care policy required hand hygiene after removing old dressings and before applying new gloves, but did not specify procedures for multiple wounds. The RN and DON acknowledged that the failure to change gloves and perform hand hygiene between treating separate wounds, especially when one was infected, could lead to cross-contamination. The observation and interviews confirmed that infection control protocols were not followed during the wound care process for this resident.