Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
Staff failed to follow infection prevention and control protocols during wound care for a resident with a stage 4 sacral pressure ulcer. Specifically, the Minimum Data Set Coordinator (MDSC) and Social Service Supervisor (SSS) did not wear gowns at the start of the procedure, and the MDSC did not use a mask or face protection while performing wound care activities that involved wound irrigation. The MDSC also double-gloved, which is not in accordance with facility policy, and did not consistently perform hand hygiene between glove changes. Supplies were placed on a chux on the bedside table, and the MDSC handled wound care materials without adhering to proper hand hygiene and personal protective equipment (PPE) protocols as outlined in the facility's Enhanced Barrier Precautions and Hand Hygiene policies. The resident involved had a history of a stage 4 pressure ulcer in the sacral region, required maximum assistance with activities of daily living, and had a catheter with frequent bowel incontinence. The wound care order required daily cleansing and dressing changes. During the observed wound care, lapses in PPE use and hand hygiene were noted, including the absence of gowns and masks, improper glove use, and inconsistent hand hygiene practices. These actions were confirmed by staff interviews and were acknowledged as not meeting facility policy requirements.