Failure to Disinfect Bedside Table During Wound Care
Penalty
Summary
The facility failed to adhere to infection prevention and control practices during wound care for a resident with a stage 2 sacral pressure ulcer. During an observed wound care procedure, an LPN entered the resident's room carrying supplies on a disposable barrier, which was placed on the foot of the bed. However, the LPN placed a bottle of hand sanitizer and clean gloves directly onto the resident's bedside table without disinfecting the surface. Throughout the procedure, the LPN repeatedly retrieved gloves and sanitizer from the undisinfected bedside table, despite removing and reapplying gloves multiple times during the dressing change. Interviews with the LPN, the Director of Nursing, and the facility's Infection Preventionist confirmed that the bedside table should have been disinfected before placing any wound care supplies on it. The LPN acknowledged not cleaning the table and recognized this as a deviation from proper infection control protocol. The resident involved was severely cognitively impaired and had a physician's order for specific wound care to the sacral area. Facility policy required maintaining a sanitary environment to minimize infection risk, which was not followed in this instance.