Failure in Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during wound care for one resident, identified as Resident 53. The facility's policy required staff to perform hand hygiene when transitioning from dirty to clean tasks during wound care. Resident 53, who was severely cognitively impaired and receiving hospice care, had a Stage 4 pressure ulcer. Physician's orders specified a detailed wound care procedure, including washing around the wound with antibacterial soap, cleansing with acetic acid solution, and applying specific dressings. During an observation of wound care, an LPN washed her hands and donned gloves before starting the procedure. However, after completing the wound care, she did not remove her gloves and wash her hands before adjusting the resident's pillow, protective heel boots, and bed controls, which was a violation of the facility's hand hygiene policy. The LPN confirmed in an interview that she did not perform hand hygiene after the wound care and before providing additional care to the resident. The Director of Nursing also confirmed that the LPN should have removed her gloves and washed her hands before moving to a clean task.
Plan Of Correction
Re-education including a return demonstration has been provided to the employee. All licensed staff will be re-educated on wound care with an emphasis on handwashing. The Director of Nursing or designee will complete 5 random auditing weekly times 4. Audits will be reviewed by the Quality Assurance Performance Improvement committee for results, areas for improvement and/or continued auditing.