Infection Control Failures in Wound Care, Laundry, and Contact Isolation Procedures
Penalty
Summary
The facility failed to implement and follow its infection prevention and control program in several key areas. During wound care for a resident with a stage 4 sacral pressure ulcer, the wound care nurse and a CNA performed the procedure without donning gowns, despite the facility's Enhanced Barrier Precautions (EBP) policy requiring gowns for wound care. Both staff members were unaware of the EBP policy and its requirements. The resident had a physician's order for daily wound care involving multiple dressings and topical treatments. The Director of Nursing also indicated uncertainty regarding the EBP policy. Additionally, the facility did not maintain proper infection control in the laundry area, as all three dryer lint compartments were observed to be full of lint, with excess lint present on the floor, contrary to the stated practice of cleaning lint traps twice daily or as needed. In another instance, staff failed to follow contact isolation procedures during incontinent care for a resident on contact precautions. While gowns and gloves were eventually worn, a CNA did not change gloves throughout the procedure and subsequently touched the resident's personal items and environment with contaminated gloves. Staff interviews revealed inconsistent knowledge and application of required PPE protocols for contact isolation.