Failure to Maintain Infection Control During Wound Care and Linen Handling
Penalty
Summary
Surveyors observed that the facility failed to maintain proper infection control practices during a wound dressing change and in the handling of soiled linens. During the dressing change for Resident #333, a soiled gown and an open trash bag containing soiled linen were found unbagged and lying on the floor under the sink. The registered nurse performing the dressing change stepped on the soiled gown while washing her hands and then proceeded with the dressing change without addressing the contamination. Additionally, a pillow with a dried blood-stained pillowcase, which the resident reported using for sleep, was used to support the resident's leg during the procedure. The pillowcase was only changed after the surveyor intervened. Throughout the observation, multiple staff members entered and exited the room but did not remove the soiled linens from under the sink. The registered nurse admitted to not bringing adequate supplies for the dressing change, as the resident was previously able to support their own leg. These actions and inactions resulted in a failure to provide a sanitary environment and to prevent the potential development and transmission of infection, as required by the facility's infection prevention and control program.