Failure to Follow Infection Control Practices During Pressure Ulcer Dressing Change
Penalty
Summary
A deficiency was identified when a nurse failed to follow infection control practices during a dressing change for a resident with a pressure ulcer who was on Enhanced Barrier Precautions (EBP). The resident, who had diagnoses including a sacral pressure ulcer, dementia, and was bedfast, required maximum assistance for personal hygiene and was at risk for developing pressure ulcers. During the observed dressing change, the nurse did not apply the required personal protective equipment (PPE) such as gown and gloves, as mandated by the facility's EBP policy. The nurse prepared a clean field, applied gloves, removed the soiled dressing, and cleansed the wound, but did not perform hand hygiene after removing gloves or before handling clean dressings. Additionally, the nurse used scissors from her scrub pocket to cut dressing material without sanitizing them, and did not perform hand hygiene before donning new gloves to apply the clean dressing. Interviews with the facility's Infection Preventionist and the nurse confirmed that these actions were not in accordance with facility policy and standard infection control practices. The facility's policies required hand hygiene at multiple steps and the use of sanitized equipment, which were not followed during this dressing change.