Failure to Follow Infection Control Practices During Wound Care
Penalty
Summary
Facility staff failed to follow infection control practices during dressing changes for a resident with multiple wounds and a urinary catheter, who was under enhanced barrier precautions. During an observed dressing change, the registered nurse and certified nurse aide washed their hands and donned gloves, but the nurse did not sanitize the over-bed table or use a barrier before placing dressing supplies. The nurse also failed to perform hand hygiene between glove changes, placed supplies directly on the resident's bed linens without a barrier, and did not use gowns as required by enhanced barrier precautions. The nurse was unclear about the requirements for personal protective equipment and hand hygiene, despite facility policy and signage indicating the need for gowns, gloves, and hand hygiene at specific points during wound care. Interviews with the nurse, unit manager, and director of nursing confirmed that the facility's policies required the use of gowns and gloves for residents on enhanced barrier precautions, a clean field for supplies, and hand hygiene between glove changes. The observed practices did not align with these policies, as the nurse did not consistently use a clean barrier, failed to perform hand hygiene at required times, and did not wear a gown during high-contact care activities. These deficiencies were confirmed through staff interviews and review of facility policies.