Failure to Follow Infection Control Practices During Wound Care Under Enhanced Barrier Precautions
Penalty
Summary
A deficiency occurred when staff failed to follow infection prevention and control practices, including CDC-referenced Enhanced Barrier Precautions (EBP), during wound care for one resident. The resident had been admitted with multiple conditions including Hidradenitis Suppurativa and was being treated for wound infections, with orders for EBP and topical Clindamycin to infected groin wounds. During an initial pool screening, the resident’s bed sheets were observed with moderately sized circular pale pink stains, and the resident reported having open wounds that sometimes drained. The CDC guidance cited in the report specifies that wound care for any skin opening requiring a dressing is a high-contact activity requiring gown and glove use, and that face protection may be needed if there is a risk of splash or spray. During an observed dressing change, the Infection Preventionist (IP) entered the resident’s room without a face covering and placed a clean drape on the bedside table along with dressing change supplies and a personal cell phone. The cell phone’s face appeared opaque with visible fingerprints and smears, and there was no observation of the phone being cleaned prior to the procedure. The IP poured wound cleaning agent from a medicine cup onto gauze held by another nurse, with the open mouth of the cup creating a potential for splashing. The IP directly handled sterile gauze with gloved hands before handing it to the nurse to pat the wounds dry, then used the same gloved hands to handle the cell phone and take close-up pictures of the draining and abscess-prone wounds. The IP again directly handled gauze with gloved hands, applied antibiotic ointment to it, and used it on the wounds. In a subsequent interview, the IP acknowledged not wearing a face covering and touching the cell phone during the dressing change, and stated disagreement with the need for a face covering because the wound was not being irrigated, while asserting the phone had been cleaned despite no prior cleaning being observed.
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