Failure to Maintain Infection Control Practices During Wound and Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for a resident with a surgical wound. Specifically, the Assistant Director of Nursing (ADON), who also served as the Infection Control Preventionist (ICP), did not demonstrate proper wound cleansing technique and did not ensure all surgical wounds were addressed during wound care. Physician orders for wound care were unclear and did not specify care for all four surgical incision areas, resulting in one wound not being treated during the observed wound care session. Additionally, the resident's room lacked Enhanced Barrier Precautions (EBP) signage and appropriate personal protective equipment (PPE) supplies, despite facility policy requiring EBP for residents with wounds. During observed care, a Certified Nursing Assistant (CNA) failed to perform hand hygiene between providing incontinent care and applying a clean brief, and then assisted with wound care without changing gloves or sanitizing hands. The CNA placed a dirty, gloved hand over an uncovered surgical wound throughout the wound care process. Both the ADON and CNA acknowledged these lapses in infection control during interviews, and the ADON confirmed that the resident should have been on EBP precautions but was overlooked. The resident involved had a history of a right hip fracture with surgical intervention, type 2 diabetes, and severely impaired cognition.