Failure to Follow Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure staff followed proper hand hygiene guidelines during wound care for a resident with multiple medical conditions, including cerebral infarction, muscle weakness, abnormal posture, hemiplegia, hemiparesis, and low back pain. The resident had documented skin disruptions and was severely cognitively impaired. Physician orders required specific wound care procedures, including cleaning and dressing the sacrum and applying protective ointment to the labia. The facility's policy outlined the need for hand hygiene before and after glove use, and between wound care steps. During an observed wound care procedure, an LPN washed hands but then touched the paper towel dispenser, reached into a uniform pocket with a gloved hand to retrieve a marker, used the marker on a clean dressing, and placed the marker on the bedside table without a barrier. The LPN then applied the dressing, changed gloves, and continued to the next wound without performing hand hygiene between treatments. The marker was not sanitized before being returned to the pocket and taken out of the room. Both the LPN and the DON confirmed that these actions were not in accordance with facility policy and proper infection control practices.