Infection Control Lapse During Wound Care
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to maintain proper infection control practices during wound care for a resident with multiple medical conditions, including a right pubic fracture, muscle weakness, and an open wound on the right elbow. The LPN donned gloves, prepared wound care supplies, and entered the resident's room. After cleaning the resident's right elbow with saline and applying antibiotic ointment with her gloved finger, the LPN removed her gloves and left the room to obtain additional supplies. Upon returning, the LPN placed a cotton-tipped applicator on the bedside table instead of the disposable tray, cleaned the resident's right knee, and again changed gloves before using the applicator to apply ointment to the knee. The LPN did not consistently change gloves between wound cleaning and ointment application and initially used her finger instead of a sterile applicator to apply ointment. The Director of Nursing (DON) observed the procedure and later confirmed that the LPN did not follow expected infection control protocols, specifically regarding glove changes and the use of sterile applicators. The facility's infection control policies provided to surveyors did not include a specific policy for general wound care or infection control practices for wounds without dressings. The observed lapses in infection control during wound care for this resident constituted a failure to prevent potential cross-contamination as required by facility policy and standard infection prevention practices.