Failure to Maintain Infection Control During Wound Care
Penalty
Summary
A deficiency occurred when a Treatment Nurse failed to follow proper infection control procedures during wound care for a female resident with chronic venous hypertension and diabetic foot ulcers. During the wound care process, the nurse wiped the resident's toes, then placed her gloved hand—contaminated from contact with the wounds—back into a package of clean gauze multiple times. The nurse subsequently closed the package and returned it to the treatment cart for future use with other residents. This action was observed by surveyors and confirmed in interviews with the nurse, the DON, and the Administrator, all of whom acknowledged the risk of contamination and infection resulting from this practice. The resident involved had been admitted with significant risk factors for infection, including chronic venous ulcers and diabetes-related foot ulcers. The facility's infection control policy required maintaining a safe and sanitary environment to prevent the transmission of disease and infection. Despite this, the nurse's actions directly contradicted established infection control protocols, as confirmed by both her own admission and statements from facility leadership.