The infection control violation occurred during treatment of Resident #7, a cognitively intact patient admitted in July with chronic obstructive pulmonary disease, stage four chronic kidney disease, and dependence on a ventilator for breathing. The resident required staff assistance with all personal care activities.
State inspectors watched LPN #205 perform the wound care procedure on October 20 at 2:16 P.M. The nurse gathered supplies including calcium alginate, scissors, normal saline, foam dressing, and gauze pads. She cleaned her scissors with alcohol and arranged materials on a clean trash bag placed over her treatment cart.
After knocking and entering the room, LPN #205 explained the procedure to the resident, who agreed to the dressing change. The nurse washed her hands, put on a gown, and covered the bedside table with a clean barrier before arranging her supplies.
The resident's physician had ordered the right lower abdomen wound to be cleansed with normal saline, patted dry, and covered with moistened collagen and foam dressing three times weekly.
LPN #205 put on gloves and removed the old dressing from the resident's right lower abdomen. Inspectors noted the wound appeared "beefy red" with intact surrounding skin and no odor. The nurse then removed her gloves and put on a new pair.
She opened gauze packages and cleansed the wound with normal saline, then removed those gloves and put on another new pair. LPN #205 placed calcium alginate in the wound and opened the silicone foam dressing.
The nurse stated she needed to date the dressing before applying it. She removed her gloves, dated the dressing, put on new gloves, and placed the foam dressing over the wound.
Throughout the entire procedure, inspectors documented that LPN #205 never washed or sanitized her hands after removing soiled gloves and before putting on clean ones. This happened four separate times during the single wound care session.
When interviewed immediately after the procedure at 2:42 P.M., LPN #205 acknowledged the violations. She verified she had not washed or sanitized her hands between glove changes and confirmed she was supposed to clean her hands before putting on new gloves each time.
The facility's own infection control policy, dated December 28, 2023, explicitly requires hand washing between glove changes during wound care. The "Clean Dressing Change" policy states nurses must "remove gloves, wash hands and put on clean gloves" multiple times throughout any dressing procedure.
The policy outlines specific steps: explain the procedure, set up a clean field, wash hands and put on gloves, place protective barriers, remove the old dressing, then "remove gloves, wash hands and put on clean gloves" before cleansing the wound.
After measuring and cleansing, the policy again requires staff to "wash hands and put on clean gloves" before applying medications and new dressings. The final step mandates discarding materials and gloves "and wash hands."
LPN #205 followed most protocol elements correctly. She gathered appropriate supplies, explained the procedure, obtained consent, used protective barriers, and changed gloves frequently. She properly assessed the wound condition and applied the prescribed treatment materials.
But her repeated failure to sanitize hands between glove changes violated fundamental infection prevention principles designed to protect vulnerable residents like #7, who depended on a ventilator and required total assistance with personal care.
The 34-bed facility received the violation under federal tag F0880, which requires nursing homes to "provide and implement an infection prevention and control program." State inspectors classified the harm level as "minimal harm or potential for actual harm" affecting one resident.
Hand hygiene represents the most basic infection control measure in healthcare settings. For residents like #7, who face heightened infection risks due to ventilator dependence and chronic kidney disease, proper hand washing protocols can mean the difference between healing and serious complications.
The nurse's admission that she knew the correct procedure but failed to follow it highlights a gap between facility policy and actual practice. Despite having detailed written protocols requiring hand hygiene at multiple points during wound care, staff execution fell short during this October inspection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Arbors At Springfield from 2025-11-19 including all violations, facility responses, and corrective action plans.