Infection Control Lapses During Wound Care and Isolation Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for two residents and two staff members, as evidenced by direct observations and interviews. In one instance, a Treatment Nurse did not change her gloves after removing a soiled dressing from a resident with a stage 3 pressure ulcer before proceeding to cleanse the wound. This action was observed during wound care, and both the nurse and the Director of Nursing (DON) acknowledged that gloves should have been changed to maintain infection control. The resident involved had dementia and muscle weakness, and her care plan required daily wound care with specific infection control measures. In another case, the Treatment Nurse did not don personal protective equipment (PPE) before entering the room of a resident under contact isolation for MRSA exposure. The nurse entered the room, moved items, and cleaned the bedside table without PPE, only applying gown and gloves after exiting and re-entering to perform wound care. Additionally, the room lacked a designated container for soiled linen, and the nurse confirmed that proper procedures were not followed. The DON and Administrator both stated that staff are expected to follow infection control policies, including donning PPE before entering rooms under contact isolation. The Laundry Supervisor was also unaware that a resident was under contact isolation, stating that no residents were currently on such precautions, despite orders indicating otherwise. Facility policies reviewed required implementation of appropriate isolation precautions and adherence to infection control best practices during wound care. These lapses in infection control practices were confirmed through interviews, observations, and record reviews.