Infection Control Lapses During Wound and Incontinence Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices involving three residents. For one resident with a wound infection and impaired cognition, the Wound Care Nurse did not perform hand hygiene when changing gloves during wound care. The nurse removed soiled gloves and immediately donned clean gloves without using hand sanitizer, despite having access to hand sanitizer in her treatment cart. The nurse acknowledged forgetting to bring the sanitizer into the room and recognized the importance of hand hygiene in preventing infection transmission. In another instance, a CNA transported a bedside table with contaminated linens from a resident's room into the hallway after providing incontinence care. The linens, which had been in the resident's room, were not bagged before being taken out, contrary to facility policy and standard infection control procedures. Both the CNA and other staff interviewed confirmed that linens should have been bagged in the resident's room to prevent cross-contamination, and that bringing potentially contaminated items into the hallway was improper. A third deficiency involved a CNA providing incontinent care to a resident with bladder and bowel incontinence and a skin wound, who was on enhanced barrier precautions. The CNA did not perform hand hygiene before or after care, failed to change gloves after cleaning soiled areas and before handling clean items, and did not wear a gown as required for residents on enhanced barrier precautions. The CNA also did not notice the precaution signage and did not use the available gown in the room. Staff interviews confirmed that these actions were inconsistent with facility policy and infection control standards.