Failure to Remove Discontinued Wound VAC with Biohazardous Drainage
Penalty
Summary
A wound VAC (Vacuum-Assisted Closure) device containing half a container of dark, thick, foul-smelling serous drainage was observed on the bedside nightstand of a resident with end stage renal disease and an open lower leg wound. The device was not in use and the drainage container was visible from the doorway. Staff interviews confirmed that the wound VAC had been discontinued several days prior, but the device and its biohazardous contents were not removed from the resident's room as required by facility infection control policy. The LPN and Infection Preventionist both acknowledged that the presence of the wound VAC with old, putrid drainage in the resident's room was an infection control concern, especially given the resident's medically compromised status. The Director of Nursing also confirmed awareness of the situation and stated that the device should have been removed immediately after discontinuation. Facility records indicated that wound care orders for the device had been discontinued, but the device and its contents remained in the room, contrary to infection control protocols.