Failure to Maintain Infection Control During Wound Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program during wound care for a resident with a Stage 3 sacrococcygeal pressure ulcer. According to the facility's wound care policy, a clean technique should be used for routine pressure ulcer dressing changes. The resident's medical record included a physician's order for daily wound care, specifying the use of wound cleanser, skin prep, Triad hydrophilic wound dressing, Medihoney, and calcium alginate with silver. During an observed wound care procedure, the treatment nurse adjusted her face mask with her right hand and did not change her gloves before continuing with the wound care, including applying skin prep and Triad cream to the periwound area. The nurse later confirmed in an interview that gloves should have been changed after touching her mask but did not recall doing so during the procedure. This lapse in infection control protocol was directly observed during the care of a resident with multiple diagnoses, including malnutrition, anemia, heart failure, and Alzheimer's disease.