Skyview Care: Contaminated Wound Care Violations - NE

Federal inspectors observed the nurse at Skyview Care and Rehab at Bridgeport push an uncovered bedside table loaded with wound care supplies down a hallway, enter a resident's room without proper protective equipment, and proceed through a series of contamination events that rendered the entire treatment unsafe.

The nurse gathered supplies and placed them on a bedside table next to the nurse's station, then pushed the table down the hall without any protective covering. After entering Resident 18's room, the nurse washed their hands but failed to put on any protective equipment before beginning the procedure.

After positioning the resident and providing privacy, the nurse used alcohol-based hand rub and placed a trash bag on the resident's bed. The nurse then put on gloves, immediately contaminating them by using both hands to reposition the bedside table.

The contamination continued as the nurse pushed down the resident's incontinence brief with the same contaminated gloves, then used those gloves to remove the old wound dressing. The nurse removed the gloves but applied new ones without performing hand hygiene first.

Using gauze with normal saline, the nurse cleaned the wound by starting at the surrounding area and working toward the center. The same single gauze pad was used to clean the entire wound, spreading potential bacteria from the outer edges directly into the wound itself.

The nurse removed the soiled gloves, applied hand sanitizer, and put on fresh gloves. But those gloves became contaminated when the nurse opened packages of alginate wound filler, skin prep, and dressing materials that had been exposed to potential contamination during the uncovered transport down the hallway.

With the same contaminated gloves, the nurse applied skin prep around the wound edges, placed the alginate filler, and applied the final dressing.

When inspectors interviewed the nurse on August 6 at 10:10 AM, the nurse confirmed they had not followed evidence-based practices for Resident 18's wound care. The nurse was unaware that contamination had occurred during the treatment procedure.

The facility's own undated hand hygiene policy requires staff to perform hand hygiene before and after coming on duty, before and after direct contact with residents, before preparing medications, and before putting on gloves. The policy also mandates hand hygiene after contact with objects in the immediate vicinity of residents.

Medication safety violations compounded the infection control failures. Inspectors observed a medication aide beginning at 8:27 AM who had just finished giving medications to another resident at 8:25 AM but started preparing the next resident's medications without performing any hand hygiene.

The medication aide also failed to sanitize the medication cart's preparation surface before beginning work. The aide used scissors to cut Resident 3's lidocaine patches in half, then used the same scissors to cut open the resident's arginaid packet without sanitizing the scissors between uses.

While preparing Resident 3's medications, the aide dispensed Tums antacid tablets into one medication cup and other medications into a second cup. The aide then placed the second cup directly on top of the first cup, allowing the bottom of the upper cup to touch the Tums tablets below.

The medication aide then put on gloves and used the same gloved hands to open Resident 3's door and assist the resident with applying medicated cream to their hip as ordered.

The inspection found that many residents were affected by these infection control failures. Federal inspectors determined the violations created minimal harm or potential for actual harm, but the systematic breakdown of basic safety protocols exposed vulnerable nursing home residents to preventable risks.

The wound care violations are particularly concerning because nursing home residents often have compromised immune systems and heal more slowly than healthy adults. Contaminated wound care can lead to serious infections that may require hospitalization or prove fatal in elderly patients with multiple health conditions.

Both incidents occurred during routine care that happens daily in nursing facilities across the country. The failures represent a breakdown in fundamental training and oversight that should prevent contamination events from occurring.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Skyview Care and Rehab At Bridgeport from 2025-08-18 including all violations, facility responses, and corrective action plans.

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