Inadequate Infection Control During Wound Care Procedure
Penalty
Summary
The deficiency involves the facility’s failure to maintain infection control practices during wound care for one resident receiving treatment to multiple lower extremity wounds. During observation of a wound dressing change, an RN providing care knelt on the tiled floor and placed both gloved hands on the floor, then used the same contaminated gloves to touch the resident’s bare skin and apply a gauze dressing to the left shin. The RN then exited the room while still wearing the gown to use hand sanitizer from a container outside the room, partially donned new gloves, reached into a pocket to retrieve a pen, and with those partially donned gloves handled gauze soaked in Dakin’s solution and placed it onto a wound on the right heel. The RN then fully donned the gloves and used the same gloved hands to write the date on the dressing, insert iodoform gauze soaked in Dakin’s solution into the right heel wound, and apply a border gauze dressing. Facility policy required that wound care be performed by licensed nursing staff using clean or sterile technique as ordered. The RN later acknowledged not realizing they had not changed gloves correctly and stated they were not very skilled at dressing changes and did not feel they had an established routine, while the DON reported the RN was nervous and should have better prepared for the wound care. The Director of Nursing identified that a total of 15 residents in the facility were receiving wound care, and the cited deficient practice was observed in one of two sampled residents reviewed for wound care during the survey.
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