The October 15 incident involved treatment of a resident's "very large deep unstageable wound" covered with yellow slough on their lower back. Inspectors watched RN #14 remove old dressing, clean the wound with soapy gauze, apply antiseptic solution, and cover it with fresh bandages — changing gloves between each step but never performing hand hygiene.
The facility's own policy, dated December 13, 2022, explicitly requires hand washing between glove changes during wound care procedures. The document states staff must "wash hands and put on clean gloves" at three separate points during dressing changes to "decrease potential for infection and/or cross-contamination."
RN #14 acknowledged the violation when questioned. During an interview 23 minutes after the observed procedure, he told inspectors that "hand hygiene should occur between glove changes" and confirmed "he did not perform hand hygiene every time he changed his gloves but should have."
The resident receiving care had been admitted to the facility in May 2015 with a medical history including peripheral vascular disease. Assessment records from September showed moderate cognitive impairment and one unstageable pressure ulcer. The wound being treated had been noted as an "opened area to the sacrum" when the resident was readmitted in July.
During the observed procedure, RN #14's technique raised additional concerns beyond the hand hygiene failures. After wiping the wound with sterile water-soaked gauze, he applied body soap and foaming cleansing soap directly to the wound bed using a 4x4 gauze pad. When he attempted to rinse the soap with water-soaked gauze, inspectors noted he "did not rinse off the soap completely, and left visible soap on the wound."
The nurse then applied Dakin's solution — a chlorine-based antiseptic — but squeezed all liquid from the gauze before placing it on the wound bed, potentially reducing the solution's effectiveness.
Each glove change represented a missed opportunity for proper infection control. The facility policy specifies seven distinct steps requiring hand hygiene and clean gloves, including after removing contaminated dressing, before wound cleansing, and before applying fresh dressing materials.
The Director of Nursing confirmed during an October 16 interview that staff should perform hand hygiene "before the procedure and during the wound care, and anytime the staff removed their gloves they should perform hand hygiene in between the glove changes."
Hand hygiene between glove changes prevents cross-contamination that can introduce harmful bacteria into open wounds. For residents with pressure ulcers, particularly deep wounds like the one observed, infection risks can lead to sepsis, delayed healing, or tissue death requiring surgical intervention.
The inspection occurred following a complaint about the facility's practices. Federal regulators classified the violation as causing "minimal harm or potential for actual harm" but noted it affected multiple residents beyond the single case observed.
Autumn Lake Healthcare at Chevy Chase has operated since at least 2015, when the affected resident was first admitted. The facility serves residents with complex medical conditions, including those requiring specialized wound care for pressure ulcers and other chronic conditions.
The wound care violation represents a fundamental breakdown in infection prevention protocols that nursing facilities are federally required to maintain. Such lapses can transform routine medical procedures into sources of serious complications for vulnerable residents.
Only after completing the entire dressing change procedure did RN #14 go to the bathroom to wash his hands — the single instance of hand hygiene during the entire observed treatment.
The resident remained in the facility with the documented pressure ulcer requiring ongoing daily care from the same nursing staff whose infection control practices had been found deficient.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Lake Healthcare At Chevy Chase from 2025-10-17 including all violations, facility responses, and corrective action plans.
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