Lack of Competency Validation and Infection Control Failures During Wound Care
Penalty
Summary
The facility failed to ensure that an agency treatment nurse had the necessary competencies and followed infection control practices while providing wound care to a resident with a stage 4 sacral pressure ulcer, type 2 diabetes, and a UTI. The resident had a physician’s order for sacral wound care that included cleansing with wound cleanser, applying gentian violet, collagen, and silver alginate, and covering with a dry dressing. During an observed wound care procedure, the agency nurse and a CNA did not wear gowns despite an Enhanced Barrier Precautions sign on the resident’s door requiring gowns and gloves for wound care. The nurse repeatedly removed soiled dressings and handled the wound and surrounding areas without performing hand hygiene between glove changes, and placed used gloves on the bedside table and bed sheets instead of discarding them appropriately. During the procedure, the resident had two bowel movements, and the nurse left and re-entered the room multiple times, changing gloves but never performing hand hygiene with sanitizer or soap and water between glove changes or before resuming wound care. The nurse confirmed in interviews that she did not bring hand sanitizer into the room, did not perform hand hygiene between glove changes, did not change gloves after cleansing the wound before applying gentian violet, and placed soiled gloves on the bed instead of discarding them. She also stated she had been performing wound care for all residents for the previous two weeks without being trained on the facility’s policies and procedures, without shadowing or receiving direction from the prior treatment nurse, and with only the physician’s orders as guidance. The administrator confirmed there was no documented evidence that this agency nurse had been trained on facility policies and procedures or that her competency to provide wound care for all residents had been verified.
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