Failure to Implement Infection Control Precautions During Wound Care
Penalty
Summary
The facility failed to implement its infection prevention and control program for a resident with significant medical needs, including a stage 4 sacral pressure ulcer, hemiplegia, and chronic kidney disease. According to facility policy, Enhanced Barrier Precautions (EBP) should be used for residents with open wounds or indwelling medical devices, requiring staff to wear gowns and gloves during high-contact care. Review of the resident's care plan showed no interventions related to EBP, despite the presence of multiple wounds and a wound vacuum. Observations revealed that staff did not follow EBP protocols during wound care procedures. The wound care nurse and physician assistant did not wear gowns, and the nurse placed a wedge pillow from the floor under the resident's back near the open wound. The end of the wound vacuum, which had touched the floor, was placed on the resident's bed pad. Additionally, gloves were changed by retrieving them from a pocket, and wound care supplies were stored in basins on the floor. The resident's room also contained stale flowers attracting flies. These findings were confirmed with staff present during the observations.