INDIANA, PA - Federal inspectors found that staff at Beacon Ridge nursing facility failed to follow basic hand hygiene protocols while treating vulnerable residents with serious circulatory conditions and open wounds, potentially exposing them to dangerous infections.
During a June 2024 inspection, surveyors observed a licensed practical nurse repeatedly skipping hand sanitization steps between glove changes while performing wound care on two residents with peripheral vascular disease—a condition that already compromises healing and increases infection risk.
Critical Lapses in Basic Infection Control
The most serious violation occurred during wound treatment for a resident with peripheral vascular disease affecting both feet. On June 4, 2024, at approximately 2:05 p.m., inspectors observed a licensed practical nurse performing a multi-step dressing change that violated the facility's own infection control policies at multiple points.
The nurse removed dressings from both of the resident's feet, then removed her gloves without washing or sanitizing her hands before putting on a new pair. She proceeded to clean the left foot with saline solution, dry it, apply betadine antiseptic, and wrap it with gauze. After completing treatment on the left foot, she again removed her gloves and immediately donned new ones—once more without any hand hygiene in between.
Only after completing the entire procedure and removing her final pair of gloves did the nurse wash her hands. This pattern represented multiple violations of hand hygiene protocol during a single wound care episode for a medically vulnerable resident.
Heightened Risk for Vascular Disease Patients
The infection control failures take on added significance given the medical conditions of the affected residents. Both individuals had documented peripheral vascular disease, a circulatory disorder that reduces blood flow to the extremities and severely compromises the body's ability to fight infection and heal wounds.
When blood flow to the feet and legs is reduced, even minor breaks in the skin can become serious medical problems. The tissue receives less oxygen and fewer infection-fighting white blood cells, creating an environment where bacteria can multiply rapidly. For patients with this condition, proper sterile technique during wound care is not merely a best practice—it can mean the difference between healing and serious complications including tissue death or systemic infection.
The residents required specialized wound treatments including betadine antiseptic applications, medihoney healing cream, and calcium alginate dressings designed for wounds with high drainage. These advanced interventions indicate the wounds were already significant medical concerns requiring meticulous care to prevent deterioration.
Pattern of Hand Hygiene Violations
The second observed incident involved similar failures during treatment of a wound on a resident's toe. At 2:41 p.m. on June 4, inspectors watched as the same nurse cleaned a wound on the third digit of a resident's right foot, applied medihoney and specialized calcium alginate dressing, then removed her gloves to begin treating a second wound on the same resident.
Again, the nurse put on new gloves without performing hand washing or sanitization between the glove changes. This practice creates potential cross-contamination between different wound sites on the same patient, as well as introducing bacteria from the nurse's hands into a sterile treatment environment.
Why Hand Hygiene Between Glove Changes Matters
Hand hygiene between glove changes serves multiple critical infection control purposes that may not be immediately obvious. Gloves can develop microscopic tears or punctures during use that are invisible to the naked eye but large enough to allow bacterial transfer. Additionally, the process of removing gloves can contaminate hands even when performed correctly, as hands may contact the exterior glove surface.
Standard infection control protocols require hand sanitization or washing after removing gloves and before donning new ones for precisely these reasons. This is especially critical in wound care settings, where open tissue provides a direct pathway for bacteria to enter the bloodstream. Healthcare-associated infections remain a leading cause of complications and mortality in long-term care facilities, with wound infections representing a significant category.
The Centers for Disease Control and Prevention identifies hand hygiene as the single most important measure for preventing healthcare-associated infections. Studies have demonstrated that proper hand hygiene can reduce infection rates by up to 50 percent in healthcare settings.
Facility's Own Policies Violated
The facility's own infection control policy, dated January 16, 2024, explicitly stated that hand hygiene is essential for preventing illness in skilled nursing facilities and that hands should be sanitized or washed both before and after glove use. The observed practices directly contradicted these written standards.
When interviewed immediately after the observations, the licensed practical nurse acknowledged that she had not performed hand hygiene after removing gloves and before putting on new ones during the wound care procedures. The Director of Nursing confirmed during a subsequent interview that the nurse should have washed or sanitized her hands between glove changes and had failed to do so.
This acknowledgment indicates that staff understood the correct procedures but failed to implement them during actual patient care—a particularly concerning finding that suggests problems with either training reinforcement or accountability systems.
Additional Issues Identified
Beyond the hand hygiene violations, the inspection revealed concerns about ensuring consistent implementation of infection control protocols across nursing staff. The facility was cited for failing to ensure proper infection prevention and control program implementation, receiving a designation of "minimal harm or potential for actual harm" affecting a few residents.
The violations fell under federal regulations requiring nursing facilities to provide and implement comprehensive infection prevention and control programs, as well as Pennsylvania state codes governing nursing services and management responsibilities.
Medical Vulnerability of Affected Residents
Assessment records showed both residents faced additional challenges beyond their vascular disease. One resident was classified as moderately cognitively impaired, while the other had severe cognitive impairment. These conditions meant the residents could not effectively advocate for themselves or recognize if infection symptoms were developing.
Cognitive impairment also complicates wound healing, as residents may not understand or comply with instructions to keep wounds clean and protected. This places even greater responsibility on staff to maintain rigorous infection control standards, as the residents cannot compensate for lapses in care.
The combination of peripheral vascular disease, cognitive impairment, and advanced age creates a perfect storm of infection risk factors. For these vulnerable individuals, every procedural shortcut or skipped safety step multiplies the danger of serious complications that could lead to hospitalization, amputation, or life-threatening sepsis.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Beacon Ridge, A Choice Comm from 2024-06-06 including all violations, facility responses, and corrective action plans.
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