Failure to Follow Standardized Infection Control Practices During Wound Care
Penalty
Summary
A deficiency occurred when staff failed to follow standardized infection control practices during a dressing change for a resident with multiple complex medical conditions, including diabetes mellitus, Parkinson's disease, and a stage three pressure ulcer on the buttock. The resident's care plan required staff to administer treatments as ordered and monitor for effectiveness, with specific physician orders directing the application of a skin substitute and Duoderm dressing. During an observed dressing change, a consultant and a licensed nurse donned gloves and a gown, removed the old dressing, cleansed the wound, measured it, applied silver nitrate, and placed a new skin substitute and Duoderm dressing. However, the consultant failed to change gloves after cleansing the wound and before performing further treatment, which was verified by the licensed nurse present. This action was not in accordance with the facility's Standard Precaution Procedure policy, which requires staff to change gloves between tasks and procedures on the same resident and after contact with potentially contaminated material. The failure to change gloves during wound care was directly observed and confirmed, constituting a breach of infection control protocol.