Infection Control and Water Management Deficiencies Identified
Penalty
Summary
During a dressing change for a pressure ulcer, a Licensed Practical Nurse (LPN) failed to follow proper infection control practices. The LPN removed an incontinent brief and wiped off old medication from a resident's sacral pressure ulcer using gloved hands, then applied new medication with the same gloves, without changing gloves or performing hand hygiene between the dirty and clean steps. The LPN later acknowledged not leaving the bedside to wash hands and change gloves as required. The resident involved was severely cognitively impaired, dependent on staff for transfers and toileting, and had multiple medical diagnoses including heart failure, renal insufficiency, and malnutrition. Additionally, the facility did not adhere to its Water Management Plan (WMP) as required. Maintenance staff confirmed that monthly monitoring of cold water temperatures and free chlorine levels, as outlined in the facility's policy for Legionnaires Disease prevention, had not been completed. This lapse had the potential to affect all residents in the facility.