Failure to Implement Infection Control Practices During Wound Care
Penalty
Summary
During a pressure ulcer dressing change for one resident, infection control practices were not followed by facility staff. The Assistant Director of Nursing (ADON) and a Certified Nursing Assistant (CNA) failed to change gloves and perform hand hygiene at appropriate times. Specifically, the CNA did not wash hands or use hand sanitizer before donning new gloves after providing incontinent care, and the ADON did not change gloves after removing a soiled dressing before applying a new one. Additionally, both staff members were not observed wearing gowns during the dressing change, and treatment supplies were placed on the resident's bed and later returned to the treatment cart without proper infection control measures. The resident involved had a stage 3 pressure ulcer of the sacral region, along with other diagnoses including dementia, diabetes mellitus, and muscle weakness. The resident's care plan identified the risk for complications from the pressure ulcer but did not include interventions for enhanced barrier precautions. Physician orders also lacked documentation for enhanced barrier precautions, despite facility policy requiring gloves and gowns during high-contact care activities for residents with wounds. Staff interviews confirmed that enhanced barrier precautions should have been implemented during the dressing change.