Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident with a right lower extremity (RLE) stasis ulcer. During wound care, an LVN did not perform hand hygiene prior to the procedure, between glove changes, or after glove removal. The LVN also used gloves that had been stored in the pocket of his scrub pants, which were considered contaminated, and did not clean the overbed table before placing treatment supplies on it. These actions were observed during a wound care procedure, and the LVN acknowledged not following proper hand hygiene protocols and not ensuring a clean field for the supplies. The resident involved was an older female with diagnoses including alcohol dependence, major depression, and muscle wasting, and had a care plan for potential impaired skin integrity. Physician orders required specific wound care procedures, including cleansing and dressing changes. Facility policies on hand hygiene and wound care were reviewed, which outlined the need for handwashing before resident contact, between glove changes, and after glove removal, as well as the use of a clean field for supplies. The LVN and DON both confirmed that the observed practices did not align with facility policy.