Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to maintain proper infection control practices during wound care for a resident with multiple non-pressure related wounds on the right foot. The resident had a history of a right foot wound that became infected prior to admission and was receiving daily wound care per physician orders, which included the application of collagen, calcium alginate, and specific dressings. During an observed wound care procedure, the LPN performed hand hygiene and donned appropriate personal protective equipment before removing the soiled dressing. However, after removing gloves, the LPN did not perform hand hygiene before donning new gloves and proceeded to clean one wound, then another, without changing gloves or performing hand hygiene between the two different wound sites. The LPN then applied treatments and dressings to both wounds without changing gloves or performing hand hygiene between steps, only removing gloves and performing hand hygiene at the end of the procedure. Additionally, the wound care provided did not follow the physician's orders, as calcium alginate was not applied to either wound and the wounds were not covered with the specified self-adherent bandage. The LPN confirmed during interview that hand hygiene was not performed at the appropriate times and that gloves were not changed between wound sites, acknowledging this as an infection control issue. The DON also stated that the expectation was for staff to follow physician orders and proper infection control practices, including hand hygiene between each step and wound.