Failure to Prevent Cross Contamination During Wound Dressing Change
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow proper infection prevention and control procedures during a dressing change for a resident with a right lateral unstageable wound. The facility's policies require the use of medical aseptic technique, including setting up a clean barrier field, performing hand hygiene after glove removal, and stopping the procedure if aseptic technique is broken. During the observed dressing change, the LPN placed dressing supplies on a towel on the resident's bed rather than on a disinfected over-bed table with a protective barrier, as required by policy. Additionally, after removing the resident's boot and sock, the LPN changed gloves but did not perform hand hygiene. After applying ointment, the LPN removed her gloves, used a pen from her pocket to date the dressing, returned the pen to her pocket, and then applied new gloves without performing hand hygiene. The LPN confirmed during an interview that she did not set up a clean barrier field and did not complete hand hygiene after glove removal, resulting in a failure to prevent cross contamination during the dressing change.