Failure to Follow Infection Control Practices During Wound Care and Respiratory Treatment
Penalty
Summary
The facility failed to adhere to established infection prevention and control practices during wound care and respiratory treatments for residents under Enhanced Barrier Precautions (EBP). During a wound care observation, the Assistant Director of Nursing (ADON) and an LPN performed hand hygiene and donned appropriate PPE before starting the procedure. However, after removing soiled gloves, the ADON failed to perform hand hygiene before donning clean gloves and proceeding with wound cleansing, which was not in accordance with the facility's hand hygiene policy. The ADON later acknowledged the missed hand hygiene step during an interview, and the Director of Nursing (DON) confirmed that hand hygiene is expected between every glove change. A review of the resident's records indicated that the resident receiving wound care had a diagnosis of hemiplegia and a stage 3 pressure ulcer, and was on Enhanced Barrier Precautions due to skin breakdown. The facility's policy and CDC guidance require strict adherence to hand hygiene and PPE use for residents with wounds or indwelling devices to prevent the spread of multidrug-resistant organisms (MDROs). In a separate incident, a respiratory therapist (RT) performed a nebulizer treatment for a resident with a tracheostomy, also under EBP, but failed to don a gown as required. Although the RT performed hand hygiene and wore gloves, the omission of the gown was contrary to both the posted EBP instructions and facility policy. The RT acknowledged the lapse during an interview, and the DON reiterated the expectation for proper PPE use during high-contact care activities for residents under EBP.