Failure to Follow Infection Control Protocol During Wound Care
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN) failed to implement proper infection control practices during wound care for a resident with an unstageable bilateral sacrococcyx pressure ulcer. The resident, who was severely cognitively impaired and dependent for activities of daily living, had physician orders specifying wound cleansing with normal saline or wound cleanser, treatment of the periwound area, application of anasept gel and collagen, and covering with a bordered dressing. During an observed wound care procedure, the LPN set up a clean field but moved wound dressing packages onto the resident's bed, which compromised the clean field. The LPN then opened the dressing packages and began wound care. While providing care, the resident had a bowel movement. The LPN provided incontinence care but proceeded to apply anasept gel to the wound bed without first cleansing the wound as required by protocol. When questioned, the LPN acknowledged the need to clean the wound after a bowel movement and subsequently did so. The infection control nurse confirmed that the expectation was for licensed nurses to maintain a clean field and reclean sacral wounds with normal saline or wound cleanser if a resident had a bowel movement.