Failure to Follow Infection Control Procedures During Wound and Incontinence Care
Penalty
Summary
Surveyors identified failures in infection control procedures during wound and incontinence care for two residents. For one resident with chronic respiratory failure, neurogenic bladder, and an indwelling catheter, staff did not follow proper hand hygiene protocols. During observed catheter and incontinence care, a State Tested Nursing Assistant (STNA) failed to perform hand hygiene after removing soiled gloves and before donning new gloves, and did not change gloves between cleaning different areas or before using clean towels. The STNA confirmed these lapses during an interview, and facility policy required hand hygiene before and after glove use. For another resident with multiple diagnoses including end stage renal disease, diabetes, and a stage three pressure ulcer, a Licensed Practical Nurse (LPN) did not don a gown while performing wound care, despite the resident being on enhanced barrier precautions due to wounds and dialysis. The LPN performed hand hygiene and changed gloves as required, but omitted the use of a gown, which was required by facility policy for high-contact care activities under enhanced barrier precautions. The LPN confirmed awareness of the precautions and the presence of PPE and signage, but did not use the gown during the procedure. Facility policies reviewed by surveyors specified the need for hand hygiene in conjunction with glove use and the use of appropriate PPE, including gowns, for residents on enhanced barrier precautions. These deficiencies were identified through direct observation, staff interviews, and review of facility policies and resident records.