Failure to Maintain Infection Control During Wound and Peri Care
Penalty
Summary
Surveyors identified that the facility failed to maintain proper infection control measures during wound care and peri care for three residents. For one resident with a stage III pressure injury and excoriation in the peri-area, two LPNs did not don gowns as required for Enhanced Barrier Precautions (EBP) during wound care. Additionally, one LPN did not perform hand hygiene after removing soiled gloves following incontinence care and before proceeding with wound care. Both LPNs confirmed in interviews that they did not wear gowns or perform hand hygiene as required by facility policy. Another resident, who was cognitively impaired and dependent on staff for most activities of daily living, developed a stage III pressure ulcer in-house. During peri care, an LPN performed hand hygiene initially but did not wear a gown for EBP and failed to perform hand hygiene after removing gloves post-care. Both the LPN and another staff member confirmed in interviews that proper PPE and hand hygiene protocols were not followed. Facility policy requires hand hygiene before and after resident contact, after glove removal, and after contact with bodily fluids. A third resident, admitted with a stage III pressure ulcer, also did not receive care in accordance with EBP protocols. During wound care, both the LPN and the Unit Manager failed to use appropriate PPE, and there was no proper notification of EBP on the resident's room. The Unit Manager confirmed the lack of PPE use and signage. Facility policy mandates the use of EBP, including PPE and signage, for residents with wounds or indwelling devices to prevent the transmission of multi-drug resistant organisms.