Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
The facility failed to adhere to established infection prevention and control protocols during wound care for three residents. Observations revealed that staff did not perform hand hygiene before donning gloves, upon entering or exiting resident rooms, or between critical steps of wound care such as removing soiled dressings, cleaning wounds, and applying new dressings. Staff also neglected to change gloves between dirty and clean tasks, and did not consistently use gowns as required by Enhanced Barrier Precautions (EBP) for residents with wounds. For one resident with heart failure, malnutrition, and quadriplegia, an LPN prepared wound care supplies, applied gloves without prior hand hygiene, and entered the room without a gown. The LPN removed a soiled dressing, during which a piece of skin tissue detached, cleansed the area, and applied a new dressing without changing gloves or performing hand hygiene. The LPN then exited the room without sanitizing hands. Similar lapses were observed with two other residents: one with severe cognitive impairment and an arterial ulcer, and another with moderate cognitive impairment, diabetes, and a surgical wound. In both cases, the LPN failed to perform hand hygiene at required intervals, did not change gloves between tasks, and did not use a gown as required by EBP. Interviews with staff and the Director of Nursing confirmed that the expected practice is to use gowns and gloves for EBP during high-contact care, and to perform hand hygiene before and after treatments, as well as between glove changes. However, the observed practices did not align with these expectations or the facility's written policies, resulting in a failure to follow acceptable standards of infection control for residents requiring wound care.