Infection Control Lapse During Wound Care Procedure
Penalty
Summary
During a wound care and dressing change procedure for a resident with venous ulcers on both lower extremities, two nurses failed to maintain proper infection control practices. The resident, who was cognitively intact and required moderate assistance with activities of daily living, had a history of Charcot joint, heart failure, diabetes, and muscle weakness. The wound care orders specified daily dressing changes using normal saline, alginate, abdominal pad, gauze, and elasticized bandage. During the observed procedure, the nurses gathered supplies, established a clean field, and donned appropriate PPE. One nurse held the resident's right leg while the other cleansed and dressed the wound, then assisted with putting on a sock and shoe. After removing gloves, the nurse did not perform hand hygiene before donning new gloves to assist with the left leg. The other nurse also did not change gloves or perform hand hygiene between handling the right and left legs. Both nurses confirmed during interview that hand hygiene was not performed after glove changes or between handling the resident's legs. The facility's wound care policy required handwashing after glove removal but did not specifically address hand hygiene between glove changes from soiled to clean gloves. This lapse in infection control procedures was identified during a complaint investigation and affected one resident out of three reviewed for wound care.