Failure to Follow Infection Control Procedures During Pressure Ulcer Care
Penalty
Summary
Facility staff failed to provide appropriate care and treatment to promote healing of pressure ulcers for one resident with multiple complex medical conditions, including type 2 diabetes mellitus, gangrene, and acute osteomyelitis. The resident was assessed as moderately cognitively impaired and had one stage 1 pressure ulcer and three unstageable pressure ulcers. During a wound care and dressing change, a registered nurse, assisted by an LPN, did not follow proper infection control procedures. Specifically, the nurse used bandage scissors that were not cleaned prior to use, failed to perform hand hygiene between glove changes, and did not change gloves or perform hand hygiene between cleaning the wound and applying the treatment dressing. Facility policies and standard clinical references provided clear instructions for hand hygiene before and after glove use, after contact with potentially contaminated materials, and before and after dressing changes. The infection preventionist confirmed that the observed practices did not meet facility expectations or policy requirements. The failure to adhere to infection control protocols during wound care was observed and discussed with facility leadership.