Infection Control Breach During Wound Care
Penalty
Summary
A deficiency was identified when a licensed nurse failed to follow infection prevention protocols during wound care for a resident with a stage four pressure ulcer. The nurse transported the entire wound care supply cart into the resident's immediate care area, contrary to facility policy and CDC guidelines, which require maintaining separation between clean and soiled equipment to prevent cross-contamination. The nurse also accessed the supply cart while in the resident's room, which is not permitted according to best practice standards and state health department literature. The resident involved required assistance with personal care and had a physician's order for daily wound treatment to the sacrum. During the observed wound care, the nurse followed the clinical treatment order but did not adhere to infection control protocols, as confirmed by the nurse at the time. This lapse in infection prevention was documented through observations, policy review, and staff interviews, and was found to be inconsistent with established infection control practices designed to prevent cross-contamination.