Failure to Follow Infection Control Practices During Wound Care
Penalty
Summary
The facility failed to implement proper infection control practices during wound dressing changes for a resident with multiple venous ulcers and a history of sepsis, renal insufficiency, and an ESBL-positive urinary tract infection. The resident required substantial assistance with activities of daily living and was on contact precautions due to infection risk. Facility policy required staff to don isolation gowns and gloves, perform hand hygiene, disinfect reusable equipment, and conduct wound care in the resident's room. Observations and interviews revealed that nursing staff did not consistently follow these protocols. One nurse was observed changing the resident's dressing at the nurse's station, failing to clean the wound, neglecting hand hygiene, and placing used items, including scissors, back into the medication cart without disinfection. Another nurse, during wound care in the resident's room, failed to change gloves or perform hand hygiene between tasks, used the same gauze to cleanse multiple wounds, and did not disinfect scissors between uses. The nurse also left the room wearing the isolation gown and handled supplies and equipment without appropriate glove changes or hand hygiene. Staff interviews confirmed a lack of adherence to infection control procedures, with admissions of forgetting to disinfect scissors and not always changing gloves or performing hand hygiene as required. The Director of Nursing stated that the expectation was for wound care to be completed in the resident's room with proper use of personal protective equipment, hand hygiene, and disinfection of reusable supplies, in accordance with facility policy. However, these practices were not consistently followed, as evidenced by direct observation and staff statements.