Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to follow proper infection prevention and control protocols during wound care for a resident with multiple complex medical conditions, including traumatic spinal cord injury, diabetes, quadriplegia, and an ESBL-resistant infection. During the wound care procedure, the RN did not perform hand hygiene between glove changes and wore two pairs of gloves simultaneously, contrary to facility policy. Additionally, the RN used scissors that had been used to cut a soiled dressing to then cut a clean dressing, without sanitizing the scissors in between uses. These actions were observed during wound care on the resident's left heel and buttock, both of which had significant wounds, including a stage 4 pressure injury. Facility policies required hand hygiene immediately after glove removal and the use of clean, sanitized equipment during wound care. The RN acknowledged not performing hand hygiene between glove changes and not sanitizing the scissors before using them on a clean dressing. The Assistant Director of Nursing confirmed that the RN's actions were not in accordance with facility protocols, specifically regarding glove use and the need for clean equipment during wound care.