F0880

D

Improper Infection Control During Wound Care for Two Residents

Broomall, Pennsylvania Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement proper infection prevention and control practices during wound care treatments for two residents. For one resident with a physician’s order dated March 8, 2026, to cleanse a right buttock wound with NSS, pat dry, apply Medihoney, and secure with a silicone border twice daily, a wound care observation on March 9, 2026, at 10:40 a.m. showed that the nurse placed tissue paper on the bed and laid wet gauze, Medihoney in a cup, and a bordered dressing on top of it. The nurse then cleansed the right buttock wound with wet gauze and discarded the gauze in a trash can, but continued the procedure by applying Medihoney and a newly opened border dressing without changing gloves or performing hand hygiene.

For a second resident with a physician’s order dated November 13, 2026, to cleanse the sacrum with NSS and apply Medihoney daily, an observation of sacral wound care on March 9, 2026, at 10:50 a.m. revealed that the same nurse opened the resident’s incontinence brief, repositioned the resident, and placed a cup with wet gauze, Medihoney in a medicine cup, and bordered gauze on top of the resident’s used incontinence brief in the bed. The nurse removed the old sacral dressing and placed it beside the clean supplies on the soiled brief, then cleaned the sacral wound with wet gauze from the cup and discarded the used gauze back into the same cup. The nurse proceeded to apply Medihoney and cover the wound with bordered gauze without changing gloves or performing hand hygiene at any point during the procedure. In a subsequent interview, the nurse acknowledged placing wound supplies on the bed due to lack of side tables and confirmed not changing gloves or performing hand hygiene, stating they forgot despite knowing it should have been done.