Failure to Disinfect Equipment and Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Staff failed to follow infection prevention and control protocols during wound care treatment and the implementation of enhanced barrier precautions (EBP) for residents with wounds and intravenous medications. In one instance, a registered nurse used scissors to remove a soiled dressing from a resident's wound without disinfecting the scissors before or after use. The same scissors were then used to cut clean dressing material, which was subsequently applied to the wound. Additionally, the resident's wound came into direct contact with an unclean surface of a recliner chair during the dressing change. The nurse confirmed that these scissors were used for wound treatments on multiple residents without proper disinfection between uses. Facility policy required reusable equipment such as scissors to be disinfected before use and after contamination, but this was not followed. In another case, a resident receiving intravenous medications for a wound infection did not have EBP implemented as required. There were no physician orders, signage, or personal protective equipment (PPE) in place to indicate EBP was being used, despite the resident having an open wound and being on IV antibiotics. The director of nursing confirmed that EBP should have been in place but was not initiated until several days after it was indicated. CDC guidance and facility policy both required EBP for residents with open wounds or indwelling medical devices, but these measures were not followed in this instance.