Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during wound care for a resident with significant medical conditions, including Type 2 Diabetes Mellitus, metabolic encephalopathy, and chronic heart failure. Observations revealed that both a CNA and the Treatment Nurse did not use a paper towel to turn off the water faucet after handwashing, instead using their bare hands, which is contrary to infection control protocols. Additionally, the Treatment Nurse used the same 4x4 gauze multiple times to wipe wounds on the resident's right great toe and left heel, rather than using a new gauze for each swipe as required to prevent cross contamination. Record reviews indicated that the resident had a deep tissue injury on the right great toe and a stage 4 pressure injury on the left heel, with care plans and physician orders specifying daily wound care and infection prevention measures. Despite documented training for staff on proper hand hygiene and wound care procedures, direct observation and interviews confirmed that these protocols were not followed during the provision of wound care, resulting in a failure to establish and maintain an effective infection prevention and control program.