Failure to Follow PPE and Hand Hygiene Protocols During Wound Care
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for two residents. Specifically, staff did not properly use evidence-based practice (EBP) personal protective equipment (PPE) during wound care for both residents. Observations revealed that a licensed vocational nurse (LVN) did not wear a gown before starting wound, colostomy, and urostomy care for a male resident with rectal cancer, colostomy, and urostomy, who was also on contact and enhanced barrier precautions. The LVN also failed to sanitize her hands between glove changes and used contaminated gloves to handle clean wound care supplies after cleaning the sacral wound area. Another LVN was observed performing wound care for a female resident with multiple diagnoses, including breast cancer and hypothyroidism, without donning a gown as required by EBP protocols. Both LVNs acknowledged during interviews that they had received training on infection control, EBP, and contact precautions, and were aware of the facility's policies and the importance of following them. The staff admitted to not following the required protocols, citing reasons such as room temperature, but demonstrated awareness of the potential for cross-contamination and infection spread. Facility policy reviews confirmed that the use of gowns and gloves during high-contact resident care activities is required, especially for residents on enhanced barrier or contact precautions. The facility's infection prevention and surveillance policy mandates ongoing monitoring and implementation of infection control procedures, and the hand hygiene policy requires sanitizing hands after glove removal and after contact with residents' skin. Despite these policies and recent staff training, the observed failures in PPE use and hand hygiene during direct care led to the identified deficiencies.