Failure to Maintain Infection Control Practices During Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices during wound care for one resident. The resident was admitted with diagnoses including surgical aftercare on the respiratory system, pulmonary embolism, and traumatic subdural hemorrhage, and was documented as cognitively impaired, bedbound, and dependent on staff for all care. A physician’s order directed that the resident’s distal midline abdominal wound be cleansed with normal saline, patted dry, covered with alginate, and then covered with an absorbent silicone dressing once daily and as needed. During an observed dressing change, an LPN removed the soiled dressing and cleansed the abdominal wound but did not change gloves before applying the clean dressing. The LPN also used scissors to cut the alginate without disinfecting the scissors prior to use. In a subsequent interview, the LPN confirmed she had not changed gloves between handling the soiled dressing and applying the clean dressing, and had not disinfected the scissors before cutting the alginate and placing it in the wound bed. The DON stated that gloves should be changed after removing a soiled dressing and before applying a clean dressing, and that scissors should be disinfected prior to cutting dressing items. Facility policies on wound treatment management and infection prevention and control, as well as CDC protocols, required adherence to current standards of practice, including cleaning reusable equipment and changing gloves when moving from a dirty site to a clean site.
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