Infection Control Lapse During Wound Care
Penalty
Summary
During wound care for a resident with chronic obstructive pulmonary disease and non-pressure wounds on both feet, infection control practices were not followed. The resident, who was moderately cognitively impaired and required staff supervision for daily activities, was observed with both feet wrapped in bandages and resting directly on the floor without shoes or socks. Physician orders specified daily wound care, including cleansing the lower extremities, applying oil emulsion, and wrapping with gauze, as well as the use of enhanced barrier precautions due to the wounds. During a wound care observation, the wound nurse removed the dressings from both feet, cleansed the left foot, and then performed hand hygiene while the resident's left foot, now undressed, rested directly on the floor. The nurse then applied new dressings to the left foot without re-cleansing it after it had made contact with the floor. The facility's policy required placing a disposable cloth under the wound to serve as a barrier, but this was not done. The Infection Preventionist confirmed that allowing the resident's feet, covered only with absorbent dressings, to be in direct contact with the floor was an infection control concern.