Failure to Prevent Cross-Contamination During Wound Care
Penalty
Summary
The facility failed to maintain a contamination-free environment during wound care for a resident receiving treatment for a pressure ulcer. Specifically, the wound nurse brought the facility's treatment cart, which contained wound care supplies for multiple residents, into the resident's room and placed supplies on top of the cart before performing wound care. This action was observed during wound care for a resident with physician orders for daily cleansing and dressing of a sacral pressure ulcer. The facility's policy for clean dressing technique specifies that the treatment cart should not be brought into the resident's room and that a clean field should be established using clean linen or a plastic field, not on the treatment cart itself. Interviews with facility staff confirmed that the treatment cart is intended to remain outside the resident's room, and the infection control coordinator verified that bringing the cart into the room is against facility policy. The wound care supplies for all residents receiving wound care were stored in the same treatment cart, which was moved from room to room, increasing the risk of cross-contamination. This practice was observed and acknowledged by staff, and the facility's own policy documentation was provided to confirm the correct procedure.