F0880

D

Inadequate Infection Control During Wound Care

Portland, Texas Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program during wound care for Resident #2. Resident #2 was an adult male with an original admission date of 02/17/2026 and a current admission date of 03/06/2026, with a pertinent diagnosis of encounter for surgical aftercare following surgery on the circulatory system. Physician orders dated 03/09/2026 directed specific wound care to the right foot surgical site, including cleansing with Dakin’s solution, rinsing with normal saline, patting dry, applying adaptic and alginate AG, lightly packing the wound bed if needed, covering with an ABD pad, wrapping with Kerlix, and securing with tape. There was also an order to practice Enhanced Barrier Precautions (EBP) when in contact with the wound and/or PICC line. Record review showed Resident #2 did not have a comprehensive care plan in the electronic record.

On 03/19/2026, during an observation of wound care, the Wound Care Nurse (WCN) and Nurse Practitioner (NP) performed multiple infection control breaches. After performing hand hygiene, both staff donned only gloves and did not put on disposable gowns before providing wound care, despite the EBP order and facility policy requiring gown and glove use for high-contact activities such as wound care. No clean barrier was placed between the resident’s right foot wounds and the dirty bed sheet. The NP leaned over the wound, allowing her hair to fall around the wound area. The WCN cleansed the wound from the outside to the inside, contrary to best practice and facility expectations to cleanse from the inner (cleanest) to outer (dirtiest) area.

Additional lapses occurred in hand hygiene and handling of contaminated materials. After wiping the bottom of the resident’s unclean foot when medicated gel ran down, the WCN continued wound care without performing hand hygiene and changing gloves. She also did not rub alcohol-based hand sanitizer over all hand surfaces until dry between glove changes. The WCN placed trash from the wound care onto the same clean barrier used for clean wound care supplies, and then performed hand hygiene and donned clean gloves before picking up the dirty tray to clean it. She carried the contaminated tray through the facility in search of sanitizing wipes, as none were available on her cart, instead of immediately cleaning it at the point of care. Interviews with the NP, WCN, and ADON confirmed that appropriate PPE (gown and gloves), correct wound cleansing technique, proper hand hygiene, and correct handling of contaminated equipment and surfaces were expected per the facility’s Enhanced Barrier Precautions and Hand Hygiene policies, but were not followed during this wound care episode.