Failure to Follow Hand Hygiene Protocol During Wound Care
Penalty
Summary
A deficiency occurred when the Wound Nurse failed to follow the facility's Handwashing/Hand Hygiene policy during a pressure ulcer treatment for a resident with a stage IV sacral pressure ulcer. The Wound Nurse initially washed her hands, donned a gown and gloves, and set up the work surface. After removing the old dressing and her gloves, she washed her hands before applying new gloves. However, after cleansing the wound and removing her gloves again, she did not wash or sanitize her hands before donning a new pair of gloves to continue the treatment, which included applying a medicated pad and border dressing. The facility's policy, last revised in October 2015, requires staff to perform hand hygiene after removing gloves and before applying new gloves. During an interview, the Wound Nurse acknowledged the lapse, stating she usually washed her hands but was nervous due to being observed. The DON confirmed that the facility's policy mandates hand hygiene after glove removal and before donning new gloves, and that the Wound Nurse did not follow this protocol during the observed wound care procedure.