Failure to Maintain Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to prevent potential cross-contamination during wound care for a resident identified as R13. The resident, who was admitted with Alzheimer's Disease, venous stasis, and congestive heart failure, was observed receiving wound care. During the procedure, an LPN donned a clean gown and gloves, removed the resident's sock, and changed gloves multiple times without performing hand hygiene between glove changes. This occurred four times throughout the dressing change, contrary to the facility's hand hygiene policy. Additionally, an RN assisted in the procedure by positioning the resident's leg and handling the garbage can without performing hand hygiene before donning new gloves. The RN used bare hands to move the garbage can and then donned gloves to continue the procedure, failing to perform hand hygiene after touching the garbage can. Both the RN and LPN confirmed during an interview that they should have performed hand hygiene before donning clean gloves, as per the facility's policy.
Plan Of Correction
Resident R13 will be examined by the physician's assistant to ensure there were no negative outcomes. Employee El and Employee E2 have completed reeducation by the Quality Registered Nurse on proper hand hygiene practices specifically related to wound care and the need for hand hygiene after touching potentially contaminated items. Random audits will be conducted by the Quality Registered Nurse on all residents receiving wound dressing changes over a two-week period to ensure proper procedures are being followed, including handwashing and that the employees perform hand hygiene after touching potentially contaminated items. All nurses, including Licensed Practical Nurses and Registered Nurses, will undergo reeducation by the Director of Nursing or her designee on the "Handwashing and Hand Hygiene" policy as it applies to wound care and the need for hand hygiene after touching potentially contaminated items. This education will be incorporated into new employee orientation under infection control procedures for new nurses being onboarded. A weekly audit on 25% of the wound care dressing changes on all shifts and hand hygiene practices will be performed by the Quality Nurse or their designee for a four-week period, followed by monthly audits thereafter. The results will be presented at the quarterly Quality Assurance Performance Improvement (QAPI) Committee. The corrective action plan will be fully implemented by April 10, 2025.