Failure to Follow Hand Hygiene Protocols During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices during wound care for one resident. The resident in question had significant medical conditions, including quadriplegia, morbid obesity, type 2 diabetes, neurogenic bowel, and was always incontinent of bowel. The resident also had multiple wounds, including pressure ulcers and surgical wounds, requiring regular wound care and dressing changes as per physician orders and care plan interventions. On three observed occasions, an LVN performed wound care for the resident and failed to follow proper infection control protocols. Specifically, the LVN removed contaminated dressings, changed gloves multiple times, and performed wound cleansing and dressing application without performing hand hygiene between glove changes. The LVN stated she believed hand hygiene was only necessary after patient care or when hands were visibly soiled, and was unaware of the facility's specific policy regarding hand hygiene between glove changes. Interviews with the treatment nurse, ADNS, DNS, and the administrator confirmed that facility policy and expectations required hand hygiene to be performed between glove changes, either by washing with soap and water or using hand sanitizer, unless hands were visibly soiled. Review of the facility's policies on wound care and hand hygiene further supported these requirements, stating that hand hygiene is the primary means to prevent the spread of infection and must be performed between glove changes. The failure to follow these protocols was directly observed and acknowledged by staff, constituting a deficiency in the facility's infection control program.