Failure to Maintain Infection Control During Wound and Incontinence Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff not adhering to proper hand hygiene and glove-changing protocols during resident care. Specifically, a Wound Care Nurse did not change gloves or perform hand hygiene after removing old dressings and before proceeding with wound cleansing and dressing changes for two residents with pressure ulcers and open wounds. The nurse continued to handle wounds and apply treatments without the required hand hygiene steps, despite having received training on infection control and wound care procedures. Additionally, two CNAs providing incontinence care to a resident did not consistently perform hand hygiene when changing gloves during the care process. One CNA changed soiled gloves without washing hands before donning new gloves, and both CNAs failed to ensure proper hand hygiene at critical points during and after care. The same CNA also handled supplies and equipment outside the resident's room without first washing hands, potentially contributing to cross contamination. The trash can used during care was not lined with a plastic bag, further increasing the risk of infection spread. Interviews with the involved staff and the Director of Nursing confirmed that the expected protocol was to perform hand hygiene and change gloves at specific points during wound care and incontinence care. Training records indicated that the staff had previously received instruction on infection control and hand hygiene, yet the observed practices did not align with facility policy or standard infection control procedures. The deficiencies were observed in residents with significant cognitive impairment and complex medical needs, including pressure ulcers and neurological conditions.