Infection Control Breach During Wound Care
Penalty
Summary
A deficiency was identified when a registered nurse (RN) failed to maintain proper infection control standards during wound care treatment for a resident with an unstageable pressure ulcer. The RN gathered wound care supplies and placed them directly on the overbed table without cleaning the surface or using a clean barrier. During the dressing change, the RN removed the soiled dressing and, without changing gloves, proceeded to cleanse the wound, apply ointment, and pack the wound, all with the same contaminated gloves. The RN also used the same gloves to handle a pen from her pocket to date the dressing and did not sanitize the overbed table after completing the procedure. The resident involved had multiple diagnoses, including cognitive communication deficit, peripheral vascular disease, depression, and anxiety disorders, and was admitted with a severe, unstageable pressure ulcer on the sacrum. The resident was on Enhanced Barrier Precautions, as indicated by signage on the door. The RN's actions during the wound care procedure did not align with the facility's policy, which requires cleaning the bedside stand, establishing a clean field, performing hand hygiene at multiple steps, and using clean technique throughout the dressing change. After completing the wound care, the RN removed her gloves but did not perform hand hygiene before leaving the resident's room. Unused supplies that had been brought into the resident's room were returned to the treatment cart without being sanitized. The RN acknowledged these breaches in infection control when interviewed, and the Director of Nursing confirmed the observed deficiencies.