Failure to Follow Infection Control Protocol During Wound Care
Penalty
Summary
A deficiency was identified when a nurse technician failed to follow proper infection prevention and control practices during a wound dressing change for a resident with an unstageable pressure ulcer on the left heel. The resident, who was cognitively intact and had diagnoses including peripheral vascular disease and type 2 diabetes, was observed during a scheduled wound care procedure. The nurse technician donned gloves and a gown, removed the resident's shoe and the old wound dressing, and handled soiled materials. However, the nurse technician did not remove her soiled gloves or perform hand hygiene after removing the old dressing and before applying the new dressing, as required by standard nursing practice and CDC guidelines. The failure to change gloves and sanitize hands between handling soiled items and applying a new dressing was confirmed by both the nurse technician and the nursing home administrator as not being in accordance with facility policy. The observation was corroborated by interviews and review of the resident's medical record, which documented the presence of a pressure ulcer and the care provided. The incident demonstrated a lapse in infection control procedures during wound care for a resident at risk due to existing medical conditions.