Infection Control Lapses in Wound Care and Contact Isolation
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for three of nine sampled residents, resulting in multiple breaches of protocol. During wound care for one resident, a treatment nurse did not perform hand hygiene or change gloves after removing a soiled dressing, and used the same gloves to handle clean supplies and enter the restroom. The nurse also used an expired alcohol-based hand sanitizer and returned unused gauze, which had been brought into the resident's room, back to the treatment cart for use with other residents. The nurse acknowledged that hand hygiene should have been performed and that unused, potentially contaminated supplies should have been discarded. A certified nursing assistant (CNA) was observed delivering meal trays and providing care in contact isolation rooms without wearing gloves or performing hand hygiene after touching contaminated items. The CNA handled residents' bedside tables, adjusted bedding, and fed a resident without gloves or hand hygiene, and then proceeded to deliver another meal tray to a different resident without sanitizing hands. The CNA admitted to not following proper personal protective equipment (PPE) and hand hygiene protocols when entering contact isolation rooms. Facility policy reviews confirmed that staff are required to perform hand hygiene after removing soiled dressings, dispose of unused disposable supplies brought into resident rooms, and wear gloves and gowns when entering contact isolation rooms. Staff interviews, including with the Director of Nursing (DON), confirmed awareness of these policies and acknowledged the observed failures to adhere to them.