Failure to Follow Infection Control Practices During Wound, Catheter, and Personal Care
Penalty
Summary
The deficiency involves the facility’s failure to follow infection prevention and control practices during wound care and other direct care for two residents. For one resident with paraplegia, multiple pressure ulcers, an indwelling catheter, and an ostomy, staff performed extensive wound and wound vac care without consistently sanitizing hands between glove changes, moved and placed wound supplies on undisinfected surfaces, and handled clean and dirty items interchangeably. During the wound care, staff removed and applied dressings to multiple wounds, manipulated the wound vac, and cleaned blood using gauze taken repeatedly from the same package, sometimes after touching contaminated items, and without always performing hand hygiene between glove changes. The suction tubing from the wound vac fell to the floor and leaked secretions, and the canister was discarded, while staff continued to work in the area. After this care, another nurse entered the room wearing gloves but no gown, removed IV medication, flushed the IV, and left the room without performing hand hygiene. For a second resident with Alzheimer’s, dementia, edema, and a history of pressure ulcers, staff also failed to adhere to infection control practices during toileting, catheter care, and wound care. A nursing assistant performed perineal care, manipulated the mechanical lift, wheelchair, catheter bag and tubing, moved equipment in and out of the room, handled a blanket and pillow, and went into the bathroom and hallway, all while wearing the same pair of gloves and without changing them until the end of the sequence. During wound care to the resident’s legs, a nurse removed heel protectors soaked in bodily fluids, dropped gauze on the floor and picked it up, and placed dressings on a chair that had not been disinfected, while intermittently changing gloves and sometimes sanitizing hands, but not consistently between all clean and dirty contacts. In a subsequent wound assessment of the second resident’s buttocks, a hospice nurse and an LPN initially provided care such as obtaining vital signs and administering medications without gowns or gloves, then donned gowns and gloves to perform wound care and catheter care. During this care, they removed dressings, washed the buttocks with wet wipes obtained from the bathroom sink, applied cream, and handled wound care supplies and the catheter cover without removing gloves or sanitizing hands between touching the resident’s buttocks and clean surfaces. Staff interviews confirmed awareness that gloves should be changed when soiled, between different tasks, and that wearing dirty gloves was an infection control issue. The DON stated that following enhanced barrier precautions and infection control was confusing.
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