Failure to Maintain Infection Control During Wound Care
Penalty
Summary
A deficiency was identified when a resident with multiple medical conditions, including dementia, stroke, Parkinson's disease, and moderate protein-calorie malnutrition, was observed to have DermaSaver Finger Separators placed directly against untreated, uncovered Stage 3 pressure ulcers on both 5th digits (pinky fingers). The resident was dependent on staff for all activities of daily living and had a history of unhealed pressure ulcers, with care plans specifying the use of dressings and moisture-wicking materials to protect the wounds and promote healing. Multiple observations revealed that the DermaSaver Finger Separators were in place without appropriate wound dressings, allowing the fabric to come into direct contact with open wounds. During wound care, an LPN removed the contaminated finger separators and placed them on a surface, then proceeded to perform wound care on the same hand without changing gloves or performing hand hygiene. The same process was repeated on the other hand, again without appropriate glove changes or hand hygiene between handling contaminated items and performing wound care. Interviews with facility staff confirmed that glove changes and hand hygiene should have occurred between removing the contaminated finger separators and performing wound care. Staff also acknowledged that the finger separators should not have been applied before wound care was completed, as this could present an infection control concern. Additionally, the facility administrator confirmed there was no specific handwashing policy in place, although handwashing competencies were conducted facility-wide.