F0880

D

Improper Wound Care Technique Leading to Cross Contamination Risk

Blair, Nebraska Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide wound care in a manner that prevented cross contamination for three residents, despite having infection control and hand hygiene policies in place. The facility’s Infection Control Guidelines and Handwashing policy required staff to perform hand hygiene after handling items potentially contaminated with blood, body fluids, secretions, contaminated linens, and after contact with broken skin. These policies also directed staff to use alcohol-based hand rub before and after direct resident contact and when moving from dirty to clean tasks. Observations of wound care for three residents showed that these procedures were not consistently followed, resulting in multiple opportunities for cross contamination of open wounds.

For one resident with multiple complex wounds and pressure injuries, including Stage 3 pressure injuries and an unstageable pressure ulcer, an RN performed wound care to the hip area in a manner that allowed the resident’s brief and blanket to come into contact with an open, undressed wound. During the dressing change, the RN removed the old dressing, pulled the brief back up over the open wound, then later pulled it down again without changing gloves between touching the brief and cleansing the wound. The RN also pushed the brief away from the wound and cleansed the wound using the same gloves without performing hand hygiene. After the blanket touched the uncovered wound, the RN re-entered the room wearing gloves, exposed the wound, and applied triad paste with a cotton-tipped applicator without changing gloves, using hand sanitizer, or re-cleaning the wound. The RN confirmed these actions, including entering the room with gloves on, not changing gloves between dirty and clean tasks, and allowing the brief and blanket to touch the open wound, created opportunities for cross contamination.

For a second resident with a Stage 3 pressure injury to the right buttock, an RN conducted wound care after donning a gown and gloves and exposing the resident’s buttock. The RN used one gloved hand to reposition the buttock and the other to apply triad paste with a cotton applicator. When the RN needed both hands to peel back the adhesive on the bordered foam dressing, the resident’s wound and triad paste came into contact with the resident’s brief. The RN then used the same gloved hand that had been repositioning the buttock to handle the clean dressing and apply it to the wound. The RN acknowledged that the contact between the wound paste and the brief, and touching the clean dressing with a contaminated glove, provided opportunities for cross contamination and that hand hygiene and glove changes should have occurred before handling the clean dressing.

For a third resident with dementia, sarcopenia, and a Stage 3 pressure injury with undermining to the left buttock, an LPN performed wound care using saline, triad paste, Gentelle Blue foam, and a silicone foam dressing. After exposing the resident’s buttocks and placing a chux pad, the LPN cleansed the wound with saline and patted it dry using gloved hands and gauze, but did not change the soiled gloves or perform hand hygiene before proceeding. The LPN then applied triad paste to the peri-wound area and allowed the resident’s buttocks to come together, causing contact between the wound area and the resident’s brief. The LPN separated the buttocks again to place the Gentelle Blue foam into the undermined wound, then released the buttocks, allowing them to close over the dressing, and used both hands to apply the silicone dressing. The LPN confirmed that allowing the buttocks to touch the brief and then close over the dressing, and failing to change gloves after cleaning the wound and before applying paste, created multiple opportunities for cross contamination of the wound.