Failure to Follow Infection Control Practices During Wound Care
Penalty
Summary
Staff 6, an LPN, was observed providing wound care to a resident admitted in December 2023 with diagnoses including diabetes. During the procedure, Staff 6 donned a gown, gloves, and face mask before entering the resident's room. She cleaned a wound on the resident's right thumb and, without changing gloves or performing hand hygiene, applied a clean dressing to the thumb, then proceeded to clean and dress a wound on the resident's left big toe. After removing her gloves, she did not perform hand hygiene before donning a new pair of gloves to apply cream to the resident's knee. Hand hygiene was only performed after leaving the resident's room. Staff 6 later acknowledged she did not change gloves between wounds and did not perform hand hygiene as required. The facility's infection preventionist confirmed that the expected practice is to perform hand hygiene before and after donning gloves and to change gloves between each wound to prevent cross-contamination.