F0880

E

Failure to Follow Wound Care Aseptic Technique and Contact Precaution PPE Requirements

Greensboro, North Carolina Survey Completed on 12-19-2025

Penalty

No penalty information released

Summary

The deficiency involves failures in infection prevention and control practices during wound care and contact isolation. Facility policies required hand hygiene before and after resident contact, before clean/aseptic procedures, after contact with body fluids or non-intact skin, after touching the patient environment, and before donning and after removing gloves. The clean dressing change policy required removal of soiled dressings with one pair of gloves, hand hygiene, then a new pair of gloves to cleanse each wound, with hand hygiene and glove changes between multiple wounds, and cleansing from least to most contaminated. During an observed wound care session for Resident #14, Nurse #3 did not follow these procedures.

For Resident #14, who had multiple wounds to the sacrum, right ischium, left buttock, and bilateral heels, Nurse #3 removed dressings from the sacrum and right ischium together by rolling them into one bundle and discarding them, then removed the dressing from the left buttock separately. After performing hand hygiene and donning clean gloves, Nurse #3 cleansed the sacral, right ischial, and left buttock wounds using multiple gauze pads but did not perform hand hygiene or change gloves between each wound. Using the same pair of gloves, Nurse #3 then packed all three wounds and applied separate clean dressings without changing gloves between wounds. For the left and right heel treatments, Nurse #3 applied a protective barrier wipe to the left heel, then cut off the soiled bandage from the right foot, placed the scissors on the overbed table, and applied the same type of barrier wipe to the right heel, again without hand hygiene or glove change between heels. When a new wound on the outer right leg was identified during this process, Nurse #3 touched it with a gloved finger that had already been used for the heel treatments.

Additional lapses occurred when Nurse #3 repositioned Resident #14 while still wearing the same soiled gloves and without performing hand hygiene before repositioning. After completing the treatment, Nurse #3 discarded supplies, removed gloves, and performed hand hygiene but did not clean the overbed table used as the work surface. In a separate observation involving Resident #13, who was on contact precautions for a multiple drug-resistant organism related to pneumonia, Nurse #2 entered the resident’s room and handled enteral feeding supplies on the overbed table while wearing gloves but without donning a gown, despite posted signage and available PPE indicating that both gown and gloves were required for every room entry. Nurse #2 later confirmed awareness that a gown was required and stated that wearing it had slipped her mind. The Infection Preventionist and Director of Nursing confirmed that facility policy and expectations required glove and gown use for contact precautions and hand hygiene with glove changes between wounds during dressing changes.