Failure to Disinfect Scissors Resulting in Cross Contamination During Wound Care
Penalty
Summary
The deficiency involves a failure to prevent cross contamination during wound care for one resident with a right second toe arterial wound. The resident’s EMR lists diagnoses including atrial fibrillation, chronic heart failure, non-pressure chronic ulcer of the right foot, and peripheral vascular disease, and the MDS documents the resident as cognitively intact and needing assistance with mobility and ADLs. A physician order directed staff to cleanse the right second toe with wound wash without scrubbing or using excessive force, then apply hydrogel to the wound bed, followed by an absorbent dressing, absorbent pad, stretch gauze, and tape. During observed wound care, an LPN set up wound supplies on the resident’s table, then removed scissors from her scrub top pocket and used them to cut the dressings to size without disinfecting the scissors before use. The LPN then placed the cut dressing directly over the resident’s right second toe wound, which had an open area with a moderate amount of yellow drainage, three yellow areas in the middle of the wound, and a red, swollen periwound. The resident reported poor circulation in the right lower leg and stated there was an infection in the right second toe wound. The LPN later confirmed she had cross contaminated the wound by using contaminated scissors, and the facility’s infection preventionist stated that scissors stored in scrub pockets should be disinfected before wound care, consistent with the facility’s aseptic dressing change policy requiring disinfection of scissors prior to and after use.
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