Federal inspectors observed the September 11 incident during a complaint investigation. The wound nurse entered Resident 93's room carrying supplies on wax paper, which she placed on an overbed table that had visible spills that hadn't been cleaned.
After washing her hands and putting on a gown and clean gloves, the nurse proceeded to use wound cleanser-soaked gauze that she had prepared earlier with her bare fingers to clean inside the resident's sacral wound.
The nurse completed the wound care by drying the wound with gauze, applying calcium alginate dressing, and securing it with bordered foam. She then gathered her supplies, removed her protective equipment, washed her hands, and left the room.
When inspectors interviewed the wound nurse later that day, she acknowledged using alcohol-based hand sanitizer before preparing the wound care supplies. But she defended her technique.
"It had never been a problem in the past," the wound nurse told inspectors, explaining that she had always prepared wound cleanser and gauze solutions without wearing gloves.
She confirmed wearing gloves only after entering the resident's room to begin the actual wound treatment.
The facility's Director of Nursing, who also serves as Infection Preventionist, contradicted the wound nurse's understanding of proper protocol. During a September 12 interview, the DON said the wound nurse should have sanitized her hands and worn gloves when touching any wound cleanser solution used to clean residents' wounds.
The DON had started her infection prevention role in October 2024, nearly a year before the violation occurred.
The facility's Administrator expressed similar expectations during her September 12 interview. She told inspectors she expected the wound nurse to follow infection control and clean dressing policies to prevent spreading multidrug-resistant organisms.
The violation represents a breakdown in basic infection control procedures during wound care, one of the most critical infection prevention points in nursing home care. Open wounds provide direct pathways for bacteria and other pathogens to enter residents' bodies.
Federal regulations require nursing homes to establish and maintain infection prevention and control programs. These programs must include procedures for handling sterile supplies and maintaining aseptic technique during wound care.
The inspection found the facility failed to ensure staff followed established infection control procedures during wound care preparation and treatment.
Pelican Health Randolph operates at 4801 Randolph Road in Charlotte. The September 17 complaint investigation resulted in minimal harm findings affecting few residents.
The wound nurse's admission that she had "always" prepared solutions without gloves suggests the practice extended beyond the single observed incident. Her statement indicates a systemic misunderstanding of infection control requirements rather than an isolated mistake.
The facility's leadership acknowledged the proper procedures but failed to ensure staff implementation. The disconnect between administrative expectations and actual practice highlights gaps in training, supervision, or both.
Wound care violations carry particular significance in nursing home settings, where residents often have compromised immune systems and multiple comorbidities that increase infection risks. Improper technique during wound preparation can introduce pathogens directly into open tissue.
The overbed table with visible spills compounds the infection risk, creating an unclean surface where sterile supplies were placed before use on the resident's wound.
The wound nurse's preparation of cleanser-soaked gauze with bare hands before the procedure began represents the most serious aspect of the violation. This practice could contaminate the solution before it ever reaches the resident's wound.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, the finding suggests broader issues with infection control training and oversight at the facility.
The September complaint investigation focused specifically on infection prevention practices. Inspectors documented the wound care violation as part of their review of the facility's compliance with federal infection control standards.
Resident 93's sacral wound required ongoing treatment with calcium alginate dressing, indicating a serious pressure injury that demanded strict aseptic technique to prevent complications.
The facility must now demonstrate corrected procedures and staff retraining to address the identified deficiencies in wound care practices.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pelican Health Randolph LLC from 2025-09-17 including all violations, facility responses, and corrective action plans.