The November 13 incident involved the assistant director of nursing, a registered nurse, and a certified nursing assistant who all failed to follow the facility's infection control protocols during wound care for a resident with a sacral pressure sore, a right buttock wound, and an indwelling urinary catheter.
Federal inspectors observed the wound care session where staff cleaned and dressed the resident's wounds without wearing the disposable gowns required by facility policy. The registered nurse cleaned the sacral wound with Dakins solution, packed it with sponge material, and attached wound vacuum tubing. He then treated the right ischium and buttock area, which showed black discolored areas and red drainage, applying santyl ointment to the wound bed.
All three staff members wore gloves but omitted the gowns mandated for residents with chronic wounds and indwelling medical devices.
When questioned later that evening, each staff member acknowledged the violation. The assistant director of nursing said at 5:22 PM that "the reason she did not place on full PPE when assisting with Foley catheter care and wound care for Resident #1 was due to her being distracted." She admitted she "placed Resident #1 at risk for cross contamination."
Eight minutes later, the registered nurse told inspectors "he was supposed to wear a gown when he changed Resident #1's wounds" and that "he forgot to put on his disposable gown." He said the lapse "placed the resident and himself at risk for cross contamination."
The nursing assistant gave a similar account at 5:35 PM, saying "she forgot to put on the disposable gown" and acknowledging that "placing on full PPE was for infection control."
The facility's director of nursing confirmed the policy breach five minutes later, explaining that staff "should have been wearing full PPE that consisted of disposable gowns and gloves when providing direct care for Resident #1 due to the resident having wounds and a Foley catheter." She said these measures "were taken to prevent cross contamination and infection control" and promised to retrain the staff.
The Crescent's own policies, updated as recently as March 2024, specifically require Enhanced Barrier Precautions for residents with chronic wounds like pressure ulcers and indwelling urinary catheters. The policy mandates gown and glove use during wound care to reduce transmission of multidrug-resistant organisms.
The facility's infection control policy, dating to November 2017, requires "a system for prevention, identifying, reporting, investigations, and controlling infections and communicable diseases for all patients, staff, volunteers, visitors, and other individuals."
The Enhanced Barrier Precautions policy states that protective equipment must be used "when performing the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care (central line, urinary catheter, feeding tube, tracheostomy), wound care."
The policy applies even when residents are not known to be infected with targeted organisms, recognizing that protective measures prevent transmission before infections develop.
Federal inspectors documented the violation under regulations requiring nursing homes to maintain infection prevention and control programs. The citation noted minimal harm or potential for actual harm affecting few residents.
The November 18 inspection was conducted in response to a complaint. All three staff members properly disposed of contaminated materials in biohazard bags and washed their hands after the procedure, but the missing gowns represented a fundamental breach of infection control protocols designed to protect both residents and healthcare workers.
The resident's wounds showed signs of ongoing healing challenges, with the right buttock area displaying black discolored tissue and drainage that required specialized cleaning and antibiotic ointment treatment. Such complex wounds in nursing home residents require strict adherence to infection control measures to prevent complications that could lead to sepsis or other life-threatening conditions.
The staff members' admissions that they forgot or were distracted highlight systemic issues with protocol compliance at the 45-bed facility. Each acknowledged understanding the requirements but failed to follow them during actual patient care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Crescent from 2025-11-18 including all violations, facility responses, and corrective action plans.