Failure to Follow Infection Control Procedures During Wound Care
Penalty
Summary
A deficiency was identified when a resident with multiple medical diagnoses, including adult failure to thrive, dementia, right hemiplegia, and paranoid schizophrenia, was not provided appropriate infection control measures during wound care. The resident had an unstageable pressure ulcer to the sacrum, as documented in weekly wound evaluations. During an observed dressing change, the LPN performed the procedure without donning a gown and failed to wash hands between glove changes, both of which are required infection control practices according to facility policy for Enhanced Barrier Precautions (EBP). Additionally, the resident did not have an EBP sign posted in the room or on the door, and there was no physician order for EBP documented in the medical record. The LPN confirmed during interview that the resident should have been under EBP and acknowledged not following the required procedures. Facility policy specifies that EBP, including the use of gown and gloves during high-contact care activities such as wound care, is necessary to prevent the transmission of multidrug-resistant organisms (MDRO), but these protocols were not followed in this instance.