Failure to Maintain Infection Control Practices During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for two residents who required specialized precautions due to their medical conditions. For one resident with a diagnosis of Clostridium difficile (C. diff) and a diabetic foot ulcer, the facility did not post appropriate contact isolation signage upon or immediately after notification of the isolation order. During wound care procedures for this resident, the Assistant Director of Nursing (ADON) did not perform hand hygiene between glove changes, and open wound care supplies were placed directly on the resident's bed, contrary to infection control protocols. The resident was unaware of the need for contact precautions, and the required signage was not present at the time of initial observation. For the second resident, who had a stage four pressure ulcer and a colostomy, the ADON also failed to sanitize her hands between glove changes while providing wound care. Both residents had care plans and physician orders that specified the need for enhanced barrier precautions, including the use of gowns and gloves during high-contact care activities. Facility policy required hand washing with soap and water after contact with residents with infectious diarrhea, such as C. diff, and after removing gloves, but these procedures were not consistently followed by staff during the observed care events. Interviews with facility staff, including the ADON, the Vice President of Clinical Services, and the Administrator, confirmed that the expected standard was for staff to wash their hands before and after care, as well as between glove changes, especially for residents on isolation precautions. The lack of proper signage and failure to adhere to hand hygiene protocols during wound care for both residents were directly observed and documented by surveyors, constituting a deficiency in the facility's infection prevention and control practices.