Failure to Maintain Infection Control Precautions During Wound Care
Penalty
Summary
Facility staff failed to maintain standard infection control precautions during wound care for two residents. Observations revealed that staff did not perform hand hygiene with glove changes, did not consistently wear personal protective gowns when required, and handled items such as glasses and treatment carts with contaminated gloves. In both cases, staff entered resident rooms and began wound care procedures without washing their hands, and did not change gloves or perform hand hygiene after touching their faces or other potentially contaminated surfaces. Additionally, staff did not always have the necessary PPE available near or outside the resident rooms, and signage indicating Enhanced Barrier Precautions (EBP) was absent. For one resident with multiple wounds and a history of heart failure, UTI, stroke, and anxiety, staff did not address wounds in the care plan or obtain a physician's order for EBP, despite the presence of wounds requiring such precautions. During wound care, staff failed to change gloves and perform hand hygiene at appropriate intervals, touched their faces and glasses with gloved hands, and handled treatment supplies with contaminated gloves. The resident's wounds were treated without adherence to EBP protocols, and staff interviews confirmed a lack of knowledge and training regarding EBP. For another resident with a stage 4 pressure ulcer and multiple stage 2 ulcers, staff similarly did not obtain a physician's order for EBP or include EBP in the care plan. During wound care, staff did not wear protective gowns as required, failed to perform hand hygiene before and after glove changes, and handled personal items and treatment supplies with contaminated gloves. Both staff members left the resident's room without performing hand hygiene. The Director of Nursing confirmed that these actions were not in line with facility expectations or policies.