Failure to Implement Infection Control and Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Facility staff failed to adhere to infection prevention and control protocols during wound care for a resident with multiple wounds. Observations revealed that an LPN did not perform hand hygiene or apply gloves before handling wound care supplies, did not clean scissors before use, and placed supplies directly on the treatment cart without a barrier. During wound care, the LPN did not use a gown, failed to change gloves and perform hand hygiene between tasks and wounds, and placed soiled items on the resident's bed and bedside table without cleaning these surfaces afterward. The LPN also used the same gloves for multiple tasks and wounds, increasing the risk of cross-contamination. The facility's policies on hand hygiene and Enhanced Barrier Precautions (EBP) require staff to perform hand hygiene before and after glove use, treat each wound individually, and use gowns and gloves for residents with chronic wounds. However, the resident's plan of care and physician orders did not include directions for EBP, and there was no signage or PPE available near the resident's room to alert staff or facilitate compliance with EBP. Interviews with the LPN, DON, and Administrator confirmed that staff were aware of the correct procedures but failed to implement them during the observed wound care. The resident involved was cognitively intact, at risk for pressure ulcers, and had multiple documented wounds requiring ongoing wound care. Despite these risk factors, the facility did not ensure that staff followed established infection control practices or that EBP protocols were implemented and communicated to staff. The lack of proper hand hygiene, glove changes, use of PPE, and environmental cleaning during wound care constituted a failure to prevent potential cross-contamination and infection.