F0880

D

Inadequate Infection Control Practices During Wound Care

Bryn Mawr, Pennsylvania Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves a failure to maintain appropriate infection prevention and control practices during wound care for one resident. The resident had been readmitted with diagnoses including cerebral infarction, right-sided hemiplegia, and aphasia following stroke, and had physician orders for daily cleansing and dressing of wounds on the right ischium and sacrum with NSS, calcium alginate, and a clean dry dressing. During observed wound care, the RN performed initial hand hygiene and donned gloves before preparing a clean field and rolling the resident onto her left side. After placing an absorbent pad, the RN removed soiled bandages from the ischial and sacral wounds and uncovered an additional area on the left inner thigh.

The RN then removed soiled gloves and donned clean gloves without performing hand hygiene, and proceeded to cleanse all three wounds with NSS without changing gloves or performing hand hygiene between wounds. When a drip from the sacral wound was noticed, the RN used a saline-soaked gauze to wipe the drip and then used the same gauze to cleanse the thigh wound. Alginate was applied to all three wounds and covered with adhesive bordered gauze using the same gloves that had been used for cleansing. After dressing the wounds, the RN gathered soiled dressings and trash into the absorbent pad and placed this bundle on the resident’s bedside table, and placed the soiled draw sheet on the resident’s chair before later disposing of them. The DON confirmed that multiple hand hygiene indications were missed, that all three wounds should not have been open at the same time, that the thigh area was excoriation that should have been treated differently, and that soiled materials should not have been placed on the bedside table or chair.