MARTINSBURG, PA - Federal inspectors cited Morrisons Cove Home for infection prevention and control violations after observing a licensed practical nurse fail to follow proper hand hygiene protocols during wound care for a resident with a Stage 4 pressure ulcer.
Infection Control Breach Observed During Inspection
During an unannounced inspection on January 24, 2025, Centers for Medicare & Medicaid Services surveyors observed Licensed Practical Nurse 3 providing wound care to a resident with multiple sclerosis who was receiving hospice care. The resident had a Stage 4 pressure ulcer on the sacrum - the most severe type of pressure wound that exposes fat tissue beneath the skin.
The nurse initially followed proper infection control procedures by washing hands, donning protective equipment, and carefully cleaning the wound according to physician orders. However, after completing the sterile wound care procedure, she failed to remove her contaminated gloves and wash her hands before touching other surfaces and providing additional care to the resident.
Specifically, the nurse touched the resident's skin below the dressing area, adjusted the resident's pillow and protective heel boots, and operated bed controls - all while wearing the same gloves used during wound care. Only after gathering supplies and disposing of waste did she finally remove her gloves and wash her hands.
Medical Significance of Hand Hygiene Protocol
Hand hygiene represents the most fundamental infection prevention measure in healthcare settings. When caring for residents with Stage 4 pressure ulcers, proper hand hygiene becomes even more critical because these deep wounds create direct pathways for bacterial contamination into underlying tissues.
Stage 4 pressure ulcers expose fat, muscle, and sometimes bone, making residents extremely vulnerable to serious infections including cellulitis, osteomyelitis (bone infection), and sepsis. The facility's own policy, updated in November 2024, specifically required staff to remove gloves and perform hand hygiene when moving from "dirty to clean" tasks to prevent cross-contamination.
The observed violation occurred during a transition from sterile wound care to routine patient care activities. By continuing to wear contaminated gloves while touching the resident's skin and adjusting personal items like pillows and heel protectors, the nurse potentially transferred bacteria from the wound site to other areas of the resident's body and immediate environment.
Facility Policy and Staff Acknowledgment
The facility's wound care policy clearly outlined requirements for infection prevention during wound treatment. The policy mandated that staff provide wound care in a manner that decreases potential for infection and cross-contamination, with specific emphasis on hand hygiene between different care tasks.
When interviewed immediately after the observation, Licensed Practical Nurse 3 confirmed that she did not remove her gloves and wash her hands after the resident's wound care and prior to providing additional care. The Director of Nursing also confirmed during the inspection that proper protocol required removing gloves and washing hands before adjusting the pillow, protective heel boots, and bed controls, as these represented a transition from contaminated to clean tasks.
Industry Standards for Wound Care Infection Control
Healthcare facilities must maintain strict infection control protocols during wound care, particularly for residents with compromised immune systems or severe wounds. The Centers for Disease Control and Prevention emphasizes that hand hygiene should occur immediately after contact with a patient's wound or contaminated surfaces, before touching clean surfaces or providing additional care.
For residents with Stage 4 pressure ulcers, infection prevention takes on heightened importance because these individuals often have multiple health conditions that impair their ability to fight infections. The resident involved in this case had multiple sclerosis and was receiving hospice care, indicating significant underlying health challenges that would make infection particularly dangerous.
Regulatory Response and Facility Requirements
The violation was classified as causing "minimal harm or potential for actual harm" and affected few residents. However, infection control breaches can have serious consequences that extend beyond the immediate incident. Poor hand hygiene practices can contribute to healthcare-associated infections, which affect hundreds of thousands of nursing home residents annually.
Federal regulations require nursing homes to maintain comprehensive infection prevention and control programs that include staff training, policy implementation, and ongoing monitoring of compliance. Facilities must ensure all staff members understand and consistently follow protocols designed to protect vulnerable residents from preventable infections.
The inspection findings highlight the importance of consistent adherence to infection control protocols, even during routine care activities. While the observed violation involved a single incident with one nurse, it demonstrates the need for ongoing education and supervision to ensure all staff members maintain proper infection prevention practices throughout their shifts.
Moving Forward
Morrisons Cove Home must develop and implement a plan of correction to address the identified deficiency. This typically includes retraining staff on proper hand hygiene protocols, implementing additional monitoring procedures, and demonstrating sustained compliance with infection control requirements.
The facility serves residents with complex medical needs, including those requiring wound care, hospice services, and assistance with daily activities. Maintaining strict infection prevention protocols protects these vulnerable individuals from complications that could significantly impact their health and quality of life.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Morrisons Cove Home from 2025-01-24 including all violations, facility responses, and corrective action plans.
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