Failure to Maintain Infection Control During Wound Care and Linen Changes
Penalty
Summary
The facility failed to maintain proper infection control measures during wound care and bed linen changes, as observed in two residents. For one resident with multiple diagnoses including diabetes, dementia, and a right scapula wound, an LPN entered the room already wearing gloves and carrying clean wound care supplies in her hand. During the procedure, the LPN repositioned the resident and handled bed linens while holding the clean dressings, causing the dressings to come into contact with the linens. The LPN then cleaned the wound and applied betadine without changing gloves or performing hand hygiene between steps, contrary to the facility's policy, which requires handwashing and glove changes at specific points during wound care. The LPN confirmed in an interview that she did not change gloves or wash her hands during the procedure. In a separate incident, another resident with severely impaired cognition and multiple chronic conditions was found to have a large pile of soiled linen on the floor in their room after a bed change. The CNA responsible stated she did not know where else to put the soiled linens. Facility policy requires soiled linens to be rolled inward and placed in a linen hamper or bag, which was not followed in this instance.