Failure to Follow Infection Control Practices During Contact Precautions and Wound Care
Penalty
Summary
A deficiency occurred when staff failed to follow appropriate infection prevention and control practices for two residents. For one resident on contact precautions due to a multi-drug resistant organism, a laundry aide entered the resident's room without donning a gown or gloves as required by the posted signage and facility policy. The aide touched the resident's bare hand with her own bare hand and later stated she was unaware of the need to use personal protective equipment (PPE) and was unsure if she had received training on isolation procedures. The resident's medical record confirmed an active physician's order for contact isolation precautions. In a separate incident, a wound care nurse performed wound care for a resident with pressure ulcers without changing gloves or performing hand hygiene between removing soiled dressings and applying new ones. The nurse acknowledged after the procedure that she should have changed gloves but did not do so. The facility's policy for clean dressing changes specifies multiple points at which hand hygiene and glove changes are required during the procedure. The Director of Nursing confirmed that the expectation is for staff to follow these infection control practices.