Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in infection control practices during wound care for two residents. During wound care for a resident with a right femur fracture, Alzheimer's disease, and dementia, RN A placed wound care supplies on an unsanitized bedside table, donned a gown that came into contact with another resident and her bed, and failed to perform hand hygiene before donning gloves. RN A also touched the resident's wound with gloved hands without changing gloves or performing hand hygiene, and after cleaning the wound, donned new gloves without hand hygiene. The trash bag used for wound care was placed on the floor and later on top of the treatment cart without sanitization. RN A acknowledged these lapses during interviews, stating that proper hand hygiene and PPE removal were not followed. For another resident with a history of cerebral infarction, major depressive disorder, generalized anxiety disorder, and aphasia, RN A washed her hands for only four seconds before removing the resident's boot and did not perform hand hygiene before donning gloves. Wound care supplies were placed on an unsanitized bedside table, and the resident's foot was repeatedly set on a trash bag containing dirty dressings and cleaning liquid. RN A failed to perform hand hygiene after removing gloves and before donning new ones, and PPE was not removed before exiting the resident's room. The used gown was placed on top of the treatment cart before disposal. RN A admitted to not following expected hand hygiene and PPE protocols during interviews. The Director of Nursing (DON) confirmed that the observed practices did not align with facility policy or professional standards, noting that contaminated items such as trash bags and gowns should not be placed on clean surfaces or treatment carts. The DON also stated that bedside tables should be sanitized before and after use, and that hand hygiene should be performed at key points during wound care. Facility policies and CDC guidelines reviewed by surveyors supported these expectations, emphasizing the importance of hand hygiene, proper PPE use, and environmental cleaning to prevent cross-contamination.