Failure to Follow Infection Control Standards During Wound and Incontinence Care
Penalty
Summary
The facility failed to adhere to infection prevention and control standards for hand hygiene, wound dressing disposal, and contaminated linen disposal for one resident who was under enhanced barrier precautions due to a coccyx wound and diagnoses of asymptomatic HIV and chronic Hepatitis B. The resident was observed in a single occupancy room with clear signage indicating the need for enhanced barrier precautions, including hand hygiene before entering and upon leaving the room, and the use of gloves and gowns for high-contact care activities such as wound care. During an observation, an LPN donned appropriate personal protective equipment (PPE) before entering the resident's room. While assisting the resident, who had a bowel movement, the LPN used a disposable brief to clean the resident and disposed of it in a trash bag placed on the floor by the room door. Without changing gloves or performing hand hygiene, the LPN touched the trash bag, room door, door handle, door frame, and requested clean bedding from a CNA. The LPN continued to touch various surfaces, including the bathroom door and sink faucet, while still wearing the same soiled gloves. The LPN then removed the resident's soiled wound dressing, cleaned the wound area, and allowed the wound to come into contact with the bed linens. The soiled dressing and PPE were disposed of in the same trash bag, and the LPN exited the room, again without performing hand hygiene, and touched additional surfaces including the medication cart before eventually using hand sanitizer in the hallway. Interviews with facility staff, including the LPN, ADON/Infection Control Nurse, and DON, confirmed that the resident was on enhanced barrier precautions and that facility policy required proper disposal of items contaminated with blood or body fluids in red biohazard bags in the dirty utility room. The facility's policy and referenced infection control guidelines emphasized the importance of hand hygiene, appropriate glove use, and proper disposal of contaminated materials to prevent the transmission of infectious agents. However, these protocols were not followed during the observed care of the resident.