Failure to Follow Hand Hygiene Protocol During Wound Care
Penalty
Summary
Nurse #1 failed to follow the facility's Handwashing/Hand Hygiene policy during wound care for Resident #2. After cleansing the resident's coccyx wound with normal saline-soaked gauze and patting it dry, Nurse #1 did not remove her gloves, perform hand hygiene, and don clean gloves before proceeding to pack the wound and apply a clean dressing. This action was observed during a wound care procedure, where the nurse transitioned from a dirty to a clean procedure without the required change of gloves and hand hygiene, as outlined in the facility's policy. The facility's policy specifically requires hand hygiene before handling clean dressings and after removing gloves, which was not followed in this instance. Nurse #1 later acknowledged the oversight, attributing it to nervousness during observation. Interviews with the Infection Preventionist, DON, and Administrator confirmed that the expectation was for staff to adhere strictly to the hand hygiene protocol, especially during wound care procedures involving a transition from dirty to clean tasks.