Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
Staff failed to follow established infection prevention and control protocols during wound care for a resident with significant medical needs, including a stage 4 pressure ulcer and indwelling medical devices. During the observed wound care procedure, both an LPN and a CNA entered the resident's room without donning gowns, despite signage indicating Enhanced Barrier Precautions (EBP) were required. The LPN brought a treatment cart into the room, placed wound care supplies directly on the bedside table without disinfecting the surface or using a barrier, and both staff members wore only gloves during the procedure. Their clothing came into contact with the resident's environment, including bed linens, increasing the risk of cross-contamination. Throughout the wound care process, the LPN did not consistently perform hand hygiene at required moments, such as after glove removal and before handling clean supplies. The LPN also handled wound care items and the resident's environment with bare hands at times, and placed unused dressing packages and clean gloves on potentially contaminated surfaces. After completing care, the LPN returned the treatment cart to the nurses' station and began disinfecting equipment, but did not observe the required dwell time for the disinfectant before placing items back into the cart, further compromising infection control. Interviews with the LPN, CNA, and Director of Nursing confirmed a lack of adherence to the facility's policies regarding PPE use, hand hygiene, and the handling of wound care supplies. The LPN and CNA acknowledged forgetting to wear gowns, and the LPN was unaware of the proper use of disinfectant products. The Director of Nursing verified that gowns should have been worn, supplies should have been handled with barriers, and items used in the resident's room should not be used for other residents. These failures resulted in a breakdown of the infection prevention and control program as required by facility policy.