Failure to Follow Standard Precautions During Multi-Site Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed its infection prevention and control program and standard precautions during wound care for a resident with multiple lower extremity wounds. The facility’s policy on Standard Precautions required hand hygiene and appropriate use of personal protective equipment (PPE), including gloves and gowns, as the primary strategy to prevent healthcare-associated infections. The resident’s medical record showed multiple diagnoses including Type 2 diabetes with diabetic mononeuropathy, cellulitis of both lower limbs, edema, chronic venous insufficiency, and neuromuscular bladder dysfunction. The resident’s MDS indicated intact cognition, partial/moderate assistance with hygiene, and an infection of the foot with purulent drainage. The care plan documented actual skin integrity impairment with arterial and venous ulcers and directed staff to treat ulcers as indicated, keep skin clean and dry, and monitor and document wound status and signs of infection. Prior to the observed wound care, the resident was seen sitting in a wheelchair in the hallway with a suprapubic indwelling catheter bag hanging on the wheelchair arm and covered for privacy. A soiled dressing with yellow drainage was observed on the right leg, and the left lower leg and left foot had no dressings in place, leaving wounds exposed with copious slough in the wound bed. Physician orders for the resident included daily and PRN wound care to multiple sites on both lower extremities and toes, specifying cleansing with normal saline, application of an antibiotic compound, and coverage with ABD pads and Kerlix wraps secured with tape. During the observed wound care, the treatment RN prepared a clean field on the bedside table with normal saline, ABD pads, gauze, scissors, and a bottle of antibiotic compound, and donned a gown and clean gloves. She removed the old dressing from the right lower anterior leg wound and then removed dressings from the left lower leg and left foot, using the same soiled gloves to pick up scissors from the clean field to cut remaining bandages and then placing the scissors on the resident’s bed. After exposing wounds with copious yellow purulent drainage, she removed her gloves and donned a new pair without performing hand hygiene. She cleansed and dressed the right anterior wound, then, without changing gloves, handled clean supplies on the bedside table and cleansed and treated three separate wounds on the left lower leg and left toe, using the same gloves throughout. The RN did not change soiled gloves between wounds and continued to reach into the clean supply area. After completing wound care, she removed her gown and gloves and walked away to discard supplies. In interviews, the treatment RN acknowledged she failed to sanitize or wash her hands between glove changes and that she used the same soiled gloves to clean three separate wounds without changing them, and the DON confirmed these findings.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.