Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during wound care for a resident with significant medical needs, including unspecified dementia and end stage renal disease. During an observed wound care procedure, the Wound Care Nurse did not change gloves between contaminated and clean tasks. Specifically, after assisting with repositioning the resident and removing the dressing, the nurse continued to handle clean wound care supplies, such as Anasept and collagen, with the same gloves. The nurse acknowledged the lapse and stated she was nervous, but recognized that gloves should have been changed prior to touching clean supplies. The resident was unable to respond to questions due to severe cognitive impairment. Interviews with the DON and Administrator confirmed that facility policy requires gloves to be changed between dirty and clean tasks during wound care, and that the Wound Care Nurse had not received specific training on cross-contamination prevention. Review of facility policies further supported the expectation for hand hygiene and glove changes during wound care procedures. The failure to follow these protocols was directly observed and acknowledged by staff, and was not in accordance with the facility's established infection control policies.