Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
A deficiency was identified when staff failed to follow proper infection prevention and control protocols during wound care for a resident. Specifically, an LPN did not don a gown prior to providing wound treatment, despite facility policy requiring the use of gowns and gloves for high-contact care activities such as wound care under Enhanced Barrier Precautions. The LPN also failed to change gloves and perform hand hygiene at appropriate times during the procedure, including after cleaning stool from the resident's buttocks and peri area, and before handling clean dressings and briefs. The resident involved had significant medical complexities, including Type 2 Diabetes Mellitus, hypothyroidism, bilateral above-knee amputations, mild cognitive impairment, peripheral vascular disease, and was dependent on staff for all care. The resident had a stage 2 pressure ulcer on the left buttock, which was acquired in the facility, and was at risk for further skin breakdown. The care plan required regular turning and repositioning, as well as adherence to wound care protocols to prevent infection and promote healing. During the observed wound care, the LPN removed a soiled brief and dressing, exposed the wound to a dirty brief, and used the same gloves for multiple tasks, including wound cleaning, dressing application, and peri care, without changing gloves or performing hand hygiene between steps. Both the LPN providing care and another LPN present confirmed in interviews that proper gown use and hand hygiene protocols were not followed, and that the wound should not have been exposed until after peri care and cleaning were completed.