Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols during a dressing change for a resident with multiple stage four pressure ulcers and a urinary catheter. Specifically, a Licensed Practical Nurse (LPN) entered the resident's room without donning a gown, as required by the facility's Enhanced Barrier Precautions (EBP) policy for residents with multi-drug resistant organisms (MDRO) and indwelling catheters. The LPN proceeded to remove the soiled dressing and cleanse the wound without performing hand hygiene between steps, contrary to the facility's wound care policy. The resident involved had a history of paraplegia and multiple stage four pressure ulcers, as well as an MDRO and a urinary catheter, necessitating strict adherence to EBP. The LPN's failure to don appropriate personal protective equipment and perform hand hygiene was confirmed during interviews with both the LPN and the Infection Control Preventionist. These actions were observed and documented during a wound care procedure, and the facility's policies clearly outlined the required infection control measures that were not followed.