Infection Control Failures During Wound Care and Catheter Management
Penalty
Summary
The facility failed to follow infection control practices during a dressing change for one resident with stage four pressure injuries to both heels. During the dressing change, an LPN placed the resident's wrapped heels on a clean barrier on the bed, then removed the dressings and placed the heels back on the same area of the barrier where the soiled dressings had been. The LPN also brought the treatment cart into the resident's room, contrary to facility expectations. The LPN later acknowledged not keeping clean and dirty areas separate on the barrier and admitted to making mistakes due to nervousness. The Interim Infection Preventionist confirmed that the nurse is expected to keep clean and dirty areas separate and not bring the wound cart into the resident's room. Additionally, the facility failed to maintain proper infection control for a resident with a suprapubic catheter. Observations showed the resident's catheter drainage bag was hanging on the side of the bed and touching the floor on two occasions. Both a CNA and an LPN confirmed that the drainage bag should not touch the floor, and the Interim Director of Nursing also acknowledged this expectation. Review of the facility's urinary catheter policy indicated that catheter tubing and drainage bags must be kept off the floor.