Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols during wound care for a resident with a left heel wound. The RN and NA assisting with the procedure performed initial hand hygiene and donned gloves, but the RN did not perform hand hygiene between glove changes while providing wound care. The RN changed gloves multiple times without washing hands in between, contrary to facility policy. Additionally, both the RN and NA did not wear gowns during the dressing change, despite facility policy requiring gown and glove use for wound care as part of Enhanced Barrier Precautions (EBP). The resident involved was cognitively intact and required assistance with footwear and repositioning. Physician orders indicated daily wound care for the left heel, use of Tubi-grip for edema, and foam booties for pressure reduction. Staff interviews confirmed awareness that gowns should have been worn and hand hygiene performed between glove changes during wound care. Facility policies reviewed specified the need for hand hygiene before clean tasks and after glove removal, as well as the use of gowns and gloves for high-contact activities such as wound care.