Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper wound care practices observed for two residents. For one resident, a 66-year-old male with diabetes, edema, kidney disease, and an arterial ulcer of the left great toe, the wound care nurse donned gloves and prepared a clean field but then contaminated the field by touching the resident's wound and subsequently retrieving clean supplies with the same gloves. The nurse placed used gauze and dirty gloves on the same surface as clean dressings and did not perform hand hygiene before donning new gloves and continuing care. For another resident, a female with a stage 4 pressure ulcer on the coccyx and a history of surgery, anxiety disorder, and kidney failure, the wound care nurse did not perform hand hygiene before starting care and failed to change gloves or wash hands at multiple points during the dressing change. The nurse removed a soiled dressing, handled clean supplies with contaminated gloves, and applied medication and a new dressing without appropriate hand hygiene or glove changes, thereby contaminating the clean field and supplies. Interviews with the wound care nurse confirmed awareness of the correct procedures, including the need for hand hygiene and glove changes, but acknowledged these steps were not followed during the observed care. The Director of Nursing, who also serves as the Infection Control Preventionist, stated that staff are expected to follow hand hygiene protocols and that training is provided during orientation and as needed. Facility policy also requires hand hygiene before and after dressing changes and after removing gloves.