Failure to Follow Infection Control Protocols During Incontinence and Wound Care
Penalty
Summary
A deficiency was identified when a licensed practical nurse (LPN) failed to adhere to proper infection prevention and control protocols during incontinence care and a wound dressing change for a resident with multiple medical conditions, including aphasia, anemia, and an unstageable pressure ulcer. The LPN did not secure her gown, resulting in her shirt and the untied gown coming into contact with the resident. During the care process, the LPN placed a soiled incontinence brief directly on the resident's bed and later handled the soiled brief with an ungloved hand before covering the resident with the same blanket. The LPN also placed soiled wound dressing and the soiled brief directly on the bedding. These actions were observed during care for a resident who was always incontinent, dependent for toileting, and had a history of skin breakdown. The facility's policies and CDC guidelines require that gowns be properly secured and that personal protective equipment be used appropriately to prevent exposure to body fluids. The LPN's failure to follow these protocols was confirmed through observation and staff interview, and was inconsistent with both facility policy and CDC recommendations for infection control.