Failure to Follow Infection Control Protocols During Wound Care and Lack of Training for Contracted Staff
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program in two key areas. First, two staff members did not adhere to required personal protective equipment (PPE) protocols while performing wound care on a resident who was under enhanced barrier precautions (EBP) due to chronic wounds. Despite clear signage and care plan instructions indicating the need for both gown and gloves during high-risk care activities such as wound care, the staff were observed wearing only gloves. Both the treatment nurse and the wound doctor confirmed during interviews that they did not wear gowns during the procedure, acknowledging this was not in compliance with facility policy and increased the risk of wound contamination. The resident involved had a history of cellulitis and required assistance with personal care. Physician orders and the care plan specifically documented the need for EBP every shift, and the resident was listed as requiring these precautions due to chronic wounds. Facility policies outlined that EBP includes the use of both gown and gloves during high-contact care activities, such as wound care, to prevent the spread of infection. Interviews with the Infection Preventionist (IP) and Director of Nursing (DON) confirmed that staff are expected to follow these protocols to minimize infection risks. Additionally, the facility failed to provide ongoing infection prevention and control training to the facility hairdresser, a contracted employee who regularly interacted with residents. The hairdresser reported not receiving any ongoing infection control training or participating in facility in-service sessions, despite an agreement requiring adherence to infection control policies. The IP confirmed that the hairdresser had never attended infection control in-services, and the DON stated that all staff, including contracted personnel, should follow the infection prevention and control program to prevent the spread of infections among residents.