Failure to Follow Hand Hygiene Protocols During Wound Care
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during a wound care treatment for a resident, as observed by a surveyor. The resident, who was cognitively intact, had a sacral wound and was receiving treatment as per physician's orders. During the treatment, the LPN did not wash her hands with soap and water before putting on gloves, nor did she perform hand hygiene after removing the resident's soiled dressing. Instead, she continued the wound care with contaminated gloves, which was against the facility's policy and CDC guidelines. The UM/LPN and the DON confirmed the surveyor's observations that the LPN did not follow the facility's hand hygiene and wound care policies. The Infection Preventionist also stated that the LPN should have performed hand hygiene before and during the wound care treatment to prevent potential infection. The facility's policies clearly outlined the steps for hand hygiene and wound care, which were not followed in this instance, leading to the deficiency.
Plan Of Correction
1. Resident #1 still resides at the facility. NJ Exec Order 26.4b1 has resulted in the deficient practice. 2. All residents have the potential to be affected by this deficient practice. 3. The Infection Preventionist re-educated all licensed nurses on the facility infection prevention policy to include but not limited to performing hand hygiene before preparing and administering wound treatments/dressing changes. Resident #1 was reviewed by the licensed nurse with NJ Exec Order 26.4b1 noted. The Infection Preventionist re-educated LPN #1 on the facility infection prevention policy to include but not limited to performing hand hygiene before preparing and NJ Exec Order 26.4b1 of any care treatment. An audit was completed during wound treatments with dressing changes to determine if nurses were following proper infection control and hand hygiene. No further variances were noted. 4. The Infection Preventionist/designee will audit during wound treatments/dressing changes to determine if nurses were following proper infection control and hand hygiene protocols. Variances will be addressed. These audits will be conducted weekly x 4 weeks, then monthly x 2 months. The findings of the audits will be submitted by the Infection Preventionist to the QAPI Committee for review and recommendation monthly for 3 months or ongoing until compliance is sustained.