Failure to Follow Infection Control Protocol During Wound Care
Penalty
Summary
During a wound dressing change for Resident #28, who had diagnoses including Alzheimer's disease, type 2 diabetes, major depressive disorder, and chronic kidney disease, the Assistant Director of Nursing (ADON) failed to follow established infection control procedures. The resident, who had severe cognitive impairment, was being treated for a skin tear on the right lower leg. The ADON removed the soiled dressing while wearing gloves, placed the soiled dressing on a paper towel on an over-bed table, and did not remove her gloves or perform hand hygiene before proceeding to the next steps of the wound care process. The ADON then used her gloved finger, which may have been contaminated from removing the soiled dressing, to apply ointment directly to the wound before covering it with a new dressing. At the time of observation, the ADON confirmed that she did not change gloves or perform hand hygiene between removing the old dressing and applying the new treatment. Review of the facility's wound care policy indicated that gloves should be changed and hand hygiene performed between these steps, but these procedures were not followed during the observed dressing change.