Failure to Change Gloves During Wound Care
Penalty
Summary
A deficiency was identified when the facility failed to ensure proper infection prevention and control practices during wound care for a resident. Specifically, the Wound Care Nurse did not change gloves between cleansing the wound and applying honey treatment and dressing, instead using the same gloves throughout the procedure. This was observed during a wound care session, where the nurse cleansed the wound, reused gauze on different areas, and then applied the prescribed honey treatment and dressing without changing gloves. The nurse acknowledged during an interview that not changing gloves could lead to infection, and the Director of Nursing confirmed that cross-contamination could occur if gloves are not changed at appropriate stages of wound care. The resident involved was a male with multiple diagnoses, including chronic pain, cellulitis, muscle wasting, cognitive impairment, and sepsis. He was totally dependent on staff for activities of daily living, always incontinent, and had a stage 3 pressure ulcer on his sacrum, with care plans and treatment orders in place for wound management. The facility's own dressing change policy required glove changes and hand hygiene at specific steps, which were not followed during the observed incident.