Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
The facility failed to maintain appropriate infection control practices during wound care for Resident #42, who had a history of ataxia, pneumonia, and acute embolism and thrombosis of the lower extremity, and was being treated for an unstageable pressure ulcer on the sacrum. During an observed wound care procedure, an LPN did not perform hand hygiene prior to donning gloves and gown, and continued to use the same pair of gloves throughout the entire wound care process. The LPN touched multiple surfaces and supplies, cleaned the wound, applied medications, and dressed the wound without changing gloves or performing hand hygiene at any point before, during, or after the procedure. Interviews with staff, including the LPN involved, another LPN, an RN supervisor, the DON, and the Administrator, confirmed that the expected practice was to perform hand hygiene before donning gloves, change gloves and perform hand hygiene between dirty and clean steps of wound care, and after removing gloves and gown. Review of the facility's dressing change policy also outlined these steps, which were not followed during the observed incident. The failure to adhere to these infection control protocols constituted a breach in infection prevention and control during wound care for Resident #42.