Improper Infection Control During Multi-Wound Dressing Change
Penalty
Summary
The deficiency involves a failure to maintain appropriate infection prevention and control practices during a pressure ulcer dressing change for Resident #16. The resident had multiple serious medical conditions, including sepsis, osteomyelitis of the vertebra, a stage IV sacral pressure ulcer, several unstageable pressure ulcers, dementia, and adult failure to thrive, and was dependent on staff for all ADLs. The care plan and physician orders included multiple wound care treatments and the use of enhanced barrier precautions (EBP), requiring staff to wear a gown and gloves during high-contact care. During an observed treatment session, the RN sanitized hands, donned gown and gloves, sanitized the bedside table, and set up supplies. The RN removed the soiled dressing from the right calf, then removed soiled dressings from the sacrum, right upper back, and right scapula using the same gloves. After removing the dressings, the RN washed hands, donned new gloves, and cleansed and dressed the wounds on the right upper back and right scapula with normal saline, calcium alginate, and bordered foam dressings, using the same gloves for both wounds. The RN then cleansed, packed, and dressed the sacral wound with normal saline, calcium alginate, and a bordered foam dressing, again without changing gloves between wounds. The RN left the room for additional supplies, washed hands, then returned and cleansed and dressed the right posterior calf wound and applied betadine to the left heel ulcer, using the same gloves for both sites. In a subsequent interview, the RN confirmed that the treatments to the five pressure ulcers were not separated, introducing the potential to spread infection from wound to wound. Facility policy on general wound and skin care required handwashing before and after resident contact and recognized that all chronic wounds are contaminated, but did not support the practice observed.
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