Infection Control Lapses in PPE Storage, Wound Care Setup, and Hand Hygiene
Penalty
Summary
The deficiency involves failures in infection prevention and control practices related to PPE storage, wound care supply handling, and hand hygiene. One resident with a stage 4 pressure ulcer, paraplegia, a suprapubic catheter, and chronic wounds had an Enhanced Barrier Precaution (EBP) gown stored unwrapped on top of personal linens in the closet, contrary to the care plan that required EBP, including gown and gloves, to reduce MDRO transmission during high-contact care. The Infection Preventionist later stated gowns are to be stored in their original plastic wrapping in the upper area of the resident’s closet and that this resident’s EBP gown should have been stored in a plastic bag. In a separate observation, the ADON prepared wound care supplies on top of a wound cart without sanitizing the cart surface and then placed the supplies on the back of a toilet in a resident’s room before moving them to a sanitized bedside table, later acknowledging a barrier should have been used between the wound care items and the surfaces. In another incident, a medication aide sanitized her hands before preparing medications, then carried the medications and water to a resident’s room, placed them on the bedside table, and applied gloves without performing hand hygiene immediately prior to glove application. The medication aide confirmed she should have performed hand hygiene before donning gloves.
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