Failure to Follow Infection Control Practices During Wound Care
Penalty
Summary
Facility staff failed to follow infection prevention and control guidelines during wound care for one resident. The facility’s wound care policy directed staff to put on exam gloves, remove the dressing, pull the glove over the dressing and discard, sanitize hands, and then put on new gloves. Resident #44 was admitted with diagnoses including COPD, dementia, and hypertension, had a physician’s order to cleanse a sacral wound with normal saline, apply calcium alginate and collagen particles, and cover with a foam dressing three times per week and as needed, and had a comprehensive care plan noting hospice services, potential for further pressure ulcer development, and a stage 4 pressure ulcer. The resident’s MDS showed a BIMS score of 00, indicating severe cognitive impairment. During an observed wound care procedure in the resident’s room, the Wound Care Nurse donned gloves and a gown, removed a soiled dressing, and then, without changing gloves or sanitizing hands, proceeded to cleanse the resident’s wounds. In subsequent interviews, the Wound Care Nurse confirmed he failed to remove gloves or sanitize his hands after removing the soiled dressing, and the DON confirmed that the nurse did not follow infection control practices during this wound care.
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