The contamination occurred during a routine wound dressing change on November 13, when the nursing director was treating a sacral wound on Resident 6. Federal inspectors observed the entire 20-minute procedure that compromised multiple sterile supplies.
The resident had been admitted with orders for daily wound care that included cleansing the sacrum with wound cleanser, applying skin prep, cutting calcium alginate dressing to fit, and covering with a border dressing. The orders had been in place since October 28.
At 3:23 PM, inspectors watched as the director of nursing gathered supplies from the wound treatment cart. She carried a plastic container, gloves, alcohol-based hand rub, and an electronic tablet to the patient's room. After gowning up and waiting for nursing assistants to position the resident on their right side, she began the wound care procedure.
The director placed a Skintegrity wound cleanser bottle and sterile gauze package on a paper towel spread across the patient's bed. She removed the soiled dressing using an alcohol wipe, changed gloves, and cleansed the wound area with the wound cleanser and sterile gauze.
Then the contamination occurred.
After laying the wound cleanser bottle back on the paper towel, the director removed her gloves and checked the patient's orders on her tablet. While she was distracted, the Skintegrity bottle rolled off the paper towel and came to rest on the resident's bedding directly next to their pillow.
The director picked up the contaminated bottle and placed it directly on the bedside table. She continued with the wound care, opening new dressings and putting on fresh gloves. She opened a package of Sorbalgon calcium alginate dressing, cut off a portion for the wound, and left the remainder in the open packaging.
After completing the dressing change and removing her protective equipment, the director made the critical error that contaminated the entire supply container. She picked up the wound cleanser bottle that had been lying on the patient's bedding and placed it back in the plastic container with all the clean wound care supplies.
The container held sealed wound care supplies, the open package of Sorbalgon, and wound measuring papers that were all now exposed to contamination from the bottle that had touched the patient's bedding.
When inspectors interviewed the director of nursing 15 minutes after the incident, she confirmed what they had observed. She acknowledged that the Skintegrity wound cleanser bottle had been lying directly on Resident 6's bedding and that she had placed it back into the plastic container with the remainder of the clean wound dressing supplies.
The director admitted this action contaminated the supplies.
The violation represents a breakdown in basic infection control protocols during wound care. Sterile supplies that come into contact with non-sterile surfaces like patient bedding can harbor bacteria and other pathogens that pose risks to vulnerable residents with open wounds.
Resident 6's wound required specialized calcium alginate dressing, which is typically used for wounds with moderate to heavy drainage. The contaminated supplies meant for this resident's ongoing care could potentially introduce harmful microorganisms directly into an open wound site.
The incident occurred despite the facility having established wound care protocols. The director of nursing, as the facility's top nursing administrator, was expected to model proper infection control procedures for other staff members.
Instead, inspectors documented a clear violation of sterile technique that compromised an entire container of wound care supplies intended for a resident with an active sacral wound requiring daily treatment.
The contamination went beyond just the wound cleanser bottle. The open package of Sorbalgon dressing and exposed wound measuring papers in the container were all compromised by the contaminated bottle's return to the supply container.
Federal inspectors classified the violation as having minimal harm or potential for actual harm, affecting few residents. However, the incident highlighted significant gaps in infection control practices at the facility's highest nursing level.
The director's acknowledgment of the contamination during the interview confirmed that she understood the severity of her error, yet the damage to the sterile supplies had already occurred during Resident 6's wound care procedure.
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 2025-11-17 including all violations, facility responses, and corrective action plans.
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