Failure to Follow Infection Control Protocols During Wound and Perineal Care
Penalty
Summary
The facility failed to implement its infection prevention and control program as evidenced by staff not adhering to established hand hygiene and perineal care protocols for two residents. During wound care for a resident with cellulitis, venous insufficiency, and edema, an LPN removed gloves five times and applied new gloves without performing hand hygiene between glove changes, contrary to facility policy and standard infection control practices. Both the LPN and the Director of Nursing acknowledged that hand hygiene should have been performed after glove removal and before donning new gloves, but it was not done during the observed procedure. In a separate incident, a CNA performing perineal care for another resident used two washcloths for cleaning and rinsing, then placed the used washcloths back into the wash basin and the used hand towel onto the resident's bedside table next to personal items. The CNA confirmed that these items were contaminated after use and should not have been placed back into the basin or on the bedside table. The facility's infection preventionist also confirmed that contaminated items should not be returned to clean areas or surfaces, indicating a breach in infection control practices during perineal care.