Diamond Care Center: Infection Control Violations - SD

Federal inspectors watched registered nurse N perform identical infection control violations during wound care for two residents on enhanced barrier precautions at Diamond Care Center on June 20, 2024.

The first violation occurred at 11:29 a.m. in the room of resident 15. Nurse N put on gown and gloves in the hallway, then used those same gloves to pick up supplies, turn on lights, move personal items, raise the bed, open the resident's brief, and handle blankets before touching a darkened area on the resident's toe directly with her contaminated gloves.

She removed those gloves and washed her hands. Then she put on new gloves and moved the bedside table, opened betadine swabs, and placed gauze next to the supply basket. When she tried to wet the gauze with betadine, she touched the gauze pad directly with her gloved fingers, then placed that same gauze on the resident's toe.

She removed the second pair of gloves and discarded them. Without washing her hands, she used tape to secure the gauze and directly touched the resident's toe while holding the gauze in place. She put the resident's sock back on and covered the resident without wearing gloves.

Less than three hours later, at 2:15 p.m., nurse N repeated nearly identical violations with resident 4.

She donned gown and gloves in the hallway, used those gloves to collect supplies and turn on lights, moved personal items and placed a paper towel on the bedside table. With the same contaminated gloves, she moved blankets, touched the resident's brief and bottom to expose a pressure area, then closed the brief and covered the resident.

She uncovered the resident's foot, removed the sock, sprayed gauze with wound spray, then sprayed the resident's toe and touched a darkened area first with wet gauze, then directly with her contaminated gloves.

After removing those gloves and washing her hands, she put on new gloves, moved the bedside table closer, opened betadine swabs and wiped the resident's toe. She took gauze from the basket, placed it on the barrier, attempted to wet it with betadine, and touched the gauze directly with her gloved fingers before placing it on the resident's toe.

She removed the gloves, discarded them, and without performing hand hygiene, used tape to secure the gauze while directly touching the resident's toe. She replaced the sock and covered the resident without gloves, then left with the supply basket.

When inspectors interviewed nurse N at 4:36 p.m., she said she was an agency nurse who had worked at the facility on and off for five years. She claimed she had completed "all dirty tasks" with one pair of gloves and "all clean tasks" with a second pair.

She preferred not to use hand sanitizer and chose to wash her hands "when necessary." She confirmed that all residents with wounds required enhanced barrier precautions with gloves and gowns for hands-on care.

Nurse N acknowledged removing her gloves to apply tape "because the tape would have stuck to my gloves." She admitted that applying tape to gauze and the resident's toe "would have been considered hands-on care."

She could not identify the missed opportunities for changing gloves and performing hand hygiene. She said she received ongoing training from her staffing agency.

The facility's MDS coordinator, registered nurse C, told inspectors the next morning that she would have expected nurse N to wash her hands before putting on gloves and after removing them. She identified "several missed opportunities" for hand hygiene and glove changes during the observed procedures.

Agency staff received orientation when they first arrived at the facility, but orientation did not include hand washing or glove use instruction. The facility expected agency staff to follow its policies, and nurse C expected the staffing agency to provide ongoing training on hand hygiene and glove use that met national standards.

If staff chose not to use hand sanitizer, they should wash their hands when hand hygiene was required, nurse C said.

The facility's hand hygiene policy required staff to perform hand hygiene immediately before and after resident care, and immediately before putting on personal protective equipment and after removing it. The policy specified that glove use does not replace hand washing or alcohol-based hand sanitizer.

The personal protective equipment policy required gloves for all resident care where contact with blood or body fluids might occur. Staff must remove gloves before touching equipment like telephones, charts, computers, monitors, doorknobs, refrigerator handles, food, or writing instruments.

Enhanced barrier precautions, according to the facility's April 2024 policy, involve gown and glove use during high-contact resident care for residents at increased risk of acquiring multidrug-resistant organisms, including residents with wounds. The policy defined wound care as "any skin opening requiring a dressing."

Both residents were on enhanced barrier precautions specifically because of their wounds. Nurse N's contamination of clean supplies and direct contact with wound sites using gloves that had touched environmental surfaces created exactly the cross-contamination risk that enhanced precautions were designed to prevent.

The violations occurred during routine wound care that nurse N had performed at the facility for five years, suggesting the infection control lapses were not isolated incidents but part of an established pattern of unsafe practice that neither the facility nor the staffing agency had identified or corrected.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Diamond Care Center from 2024-06-21 including all violations, facility responses, and corrective action plans.

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