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Based on medical record review, observation, and interview, the facility failed to follow infection control guidelines during wound care for one (#3) patient of one patient observed during wound care.

The findings included:

Medical record review revealed Patient #3 was admitted to Building A on 3/4/15 for diagnoses including Ovarian Cancer and Sepsis. Continued medical record review revealed the patient had a large abdominal wound with a wound vacuum assisted closure (VAC) device.

Medical record review of a physician's order dated 3/13/15 revealed "...consult wound care nurse...abd [abdominal] wound...wound VAC [change] M/W/F [Monday, Wednesday, Friday] to LLQ [left lower quadrant] wound..."

Observation with Registered Nurse (RN) #1 on 3/18/15 at 9:35 AM, in the patient's room, revealed RN #1 washed her hands, applied sterile gloves, and cleansed the patient's wound with normal saline and sterile gauze. Further observation revealed she applied a no sting barrier around the wound, applied an adhesive dressing around the wound, placed the VAC foam dressing inside of the wound, and then applied an adhesive dressing over the wound site, without removing her gloves and washing her hands. Continued review revealed RN #1 dropped an ink pen on the floor, picked up the ink pen, placed it on the patient's bedside table, and then removed her gloves and washed her hands.

Interview with RN #1 on 3/18/15 at 10:00 AM, in the nurses station, confirmed the dirty gloves were not changed after cleaning the patient's wound and before applying the clean dressing. Continued interview confirmed RN #1 picked up the ink pen from the floor with dirty gloves and placed on the patient's bedside table. Further interview confirmed RN #1 did not follow infection control guidelines.