Failure to Prevent Cross-Contamination During Wound Care Procedures
Penalty
Summary
The facility failed to prevent potential cross-contamination during wound care procedures for two residents. According to the facility's wound care policy, a clean field must be established using a disposable cloth or paper towel before placing wound care supplies on a resident's overbed table. However, during wound care for one resident, the Director of Nursing (DON) placed clean wound care supplies directly on the resident's bed without first placing a clean barrier. The DON also placed items such as a permanent marker, binder, and wound care supplies on the bed, and returned used items like scissors and partially used dressings to the container with clean supplies. Both the DON and the Regional Nurse Consultant confirmed that a clean barrier should have been used. For another resident, the DON initially placed wound care supplies on a paper towel on the resident's bed, but during the procedure, the wound cleanser bottle rolled off the paper towel and came into direct contact with the resident's bedding. The DON then placed the bottle back into the container with other clean wound care supplies. Additionally, open packages of dressings and wound measuring papers were left exposed inside the container with clean supplies. These actions were observed during wound care procedures and confirmed through interviews with the DON. The observations and interviews revealed that the facility did not consistently follow its own infection prevention and control policies during wound care, specifically regarding the use of clean barriers and the handling of wound care supplies. This created the potential for cross-contamination of supplies and compromised the sterile field required for proper wound care.