Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
During a wound care observation for a resident with multiple diagnoses including hemiparesis, Alzheimer's dementia, peripheral vascular disease, and a stage IV pressure ulcer, staff failed to adhere to proper infection control techniques as outlined in facility policy. The resident was under Enhanced Barrier Precautions (EBP) due to the presence of a wound. Staff involved in the dressing change initially performed hand hygiene and donned gowns and gloves. However, during the procedure, one LPN exited the resident's room wearing the same isolation gown to retrieve wound cleanser and re-entered without changing the gown. Additionally, gloves were changed multiple times without performing hand hygiene between glove changes, contrary to policy requirements. Further, after completing the wound care, the LPN exited and re-entered the room with the same gown and gloves to date and initial the dressing, again failing to remove PPE as required. Interviews with the LPN and the Director of Nursing confirmed that these actions did not comply with facility policies for EBP and aseptic dressing changes, which require removal of gowns and gloves before exiting a resident's room and performing hand hygiene between glove changes. The facility's policies were reviewed and confirmed to include these steps, but staff did not follow them during the observed wound care procedure.