Failure to Follow Infection Control Guidelines During Wound Care
Penalty
Summary
During wound care observations for two residents with stage three pressure ulcers, the facility failed to adhere to established infection control guidelines. For the first resident, who was cognitively intact and had a pressure ulcer on the left buttock, the Wound Care Nurse (WCN) did not remove dirty gloves, sanitize hands, or don clean gloves at appropriate intervals during the wound care process. Specifically, after assisting with repositioning and before removing the old dressing, the WCN failed to change gloves and sanitize hands. Additionally, the WCN did not sanitize hands between glove changes when handling clean wound care supplies and dressings. For the second resident, who had respiratory failure, anoxic brain injury, and an unhealed stage three pressure ulcer, similar lapses were observed. The WCN did not sanitize the overbed table before placing a clean barrier, failed to sanitize hands between glove changes, and used scissors to cut dressing material without sanitizing them beforehand. The WCN also did not open dressing supply packages prior to performing wound care, as required by infection control protocols. Interviews with the WCN, Infection Preventionist, and Director of Nursing confirmed that the observed practices did not align with facility expectations or infection control standards. The facility's wound treatment management policy did not specify infection control guidelines to be followed during wound care, contributing to the observed deficiencies.