Infection Control Failures During Wound Care and Respiratory Equipment Storage
Penalty
Summary
The facility failed to implement proper infection control practices during wound care for a resident with multiple wounds and failed to ensure correct storage of respiratory equipment for another resident. During a wound care observation, a nurse did not follow established protocols, including not donning a gown for Enhanced Barrier Precautions (EBP), not placing a barrier under wound care supplies, and not changing gloves or sanitizing hands between clean and dirty tasks. The nurse also used scissors from her pocket without cleaning them between uses and did not sanitize her hands until the end of the procedure. These actions were inconsistent with facility policies that require hand hygiene, use of PPE, and prevention of cross-contamination during wound care. The resident involved in the wound care deficiency had a history of type 2 diabetes, cellulitis, pressure-induced deep tissue injuries, and required extensive assistance with activities of daily living due to severe cognitive impairment. The nurse performed wound care on multiple sites without changing gloves between tasks or wounds, handled clean and dirty items with the same gloves, and failed to use a clean field for supplies. The nurse also did not follow EBP requirements for gown use and did not ensure that EBP signage and supplies were present outside the resident's room after a room change. For another resident with chronic obstructive pulmonary disease and acute respiratory distress syndrome, the facility did not ensure that oxygen cannulas and nebulizer equipment were stored in accordance with infection control policies. The oxygen tubing and nebulizer mask were repeatedly observed uncovered and not bagged when not in use, being left on the bed rail or bedside dresser. The resident confirmed that no covering was provided for the oxygen tubing, and staff interviews verified that the equipment was not stored as required by policy.