Failure to Follow Infection Control Practices During Wound Care and Equipment Cleaning
Penalty
Summary
Staff failed to maintain proper infection prevention and control practices during wound care and equipment cleaning. Specifically, an LPN did not perform hand hygiene between glove changes while providing wound care to a resident with quadriplegia and pressure ulcers. The LPN removed soiled dressings, changed gloves without performing hand hygiene, and did not change gloves after cleansing the wounds before applying new dressings. The LPN later stated uncertainty regarding the facility's hand hygiene policy and acknowledged the correct procedure was not followed. Additionally, staff did not clean a Hoyer lift after use, leaving it in the hallway for over 20 minutes without disinfection between resident transfers. A nurse confirmed that the lift should have been cleaned immediately after use. These lapses were observed during care of a resident with multiple pressure ulcers and during resident transfers, contrary to the facility's established policies for hand hygiene, wound care, and equipment cleaning.