Failure to Follow Infection Control Practices During Wound Care and Oxygen Use
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate infection prevention and control practices during wound care and oxygen administration for a resident with multiple chronic conditions, including Alzheimer’s disease, dementia, adult failure to thrive, type 2 diabetes mellitus, and chronic ischemic heart disease. The resident had active physician orders for wound care to the right buttock, sacrum, and both heels, specifying cleansing with normal saline or wound cleanser, patting dry, applying betadine where ordered, and covering with appropriate dressings, as well as use of a low air loss mattress. During an observation of wound care, the wound care nurse (V3) cleansed the sacral wound area and then applied a clean dressing without performing hand hygiene in between steps. V3 then changed the dressing on the right heel, again without performing hand hygiene between tasks, contrary to the facility’s Dressing Change (Clean/Non-Sterile) policy, which requires removal of soiled gloves, handwashing or use of alcohol-based hand gel, and then application of clean gloves before proceeding. In addition, the resident was observed lying in bed with oxygen in use at 2 L via nasal cannula, and the oxygen tubing had no label indicating the date it was changed. V3 stated that oxygen tubing should have a label with the date to indicate when it was changed for infection control purposes. The DON (V2) acknowledged that hand hygiene is required between wound dressing changes and that oxygen use should have a physician’s order and the tubing should be labeled with the date, consistent with the facility’s Oxygen Therapy policy, which requires disposable cannulas and tubing to be discarded after use in accordance with an equipment change schedule. These observations demonstrate that the facility did not follow its own infection control and treatment policies during wound care and oxygen administration for this resident.
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