Failure to Maintain Infection Control During Wound Care
Penalty
Summary
During wound care for a resident with multiple diagnoses including hemiparesis, Alzheimer's dementia, peripheral vascular disease, and a stage IV pressure ulcer, staff failed to maintain proper infection control techniques as required by facility policy and Enhanced Barrier Precautions (EBP). The resident was dependent on staff for activities of daily living and required EBP due to the presence of a severe wound. Observations revealed that staff did not consistently perform hand hygiene between glove changes, exited and re-entered the resident's room wearing the same gown and gloves, and failed to remove personal protective equipment (PPE) before leaving the room. Supplies were not gathered prior to beginning care, resulting in staff leaving the room mid-procedure while still wearing PPE. Interviews with staff and the Director of Nursing confirmed that these actions were not in accordance with facility policies for aseptic dressing changes and EBP, which require hand hygiene at specific points during wound care and the removal of gowns and gloves before exiting a resident's room. The facility's own policies outlined the necessary steps for infection prevention, but these were not followed during the observed wound care procedure for the resident.