Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
Licensed staff failed to perform proper hand hygiene during wound care for one resident. Specifically, a staff member removed the dressing from the resident's right great toe, cleaned the wound, and applied a new dressing without washing his hands between steps. The same staff member then proceeded to treat another wound, an abrasion on the left heel, without changing gloves or washing hands between the two wound care treatments. During an interview, the staff member acknowledged not removing gloves or washing hands after treating each wound and stated awareness of the correct procedure. The resident involved had multiple medical conditions, including chronic respiratory failure, transient ischemic attack, and diabetes mellitus, and was dependent on staff for all activities of daily living. The resident was also at risk for developing pressure ulcers. Facility policy and procedures reviewed indicated that hand hygiene is the primary means to prevent the spread of infections and that gloves do not replace hand washing. The observed actions were not in accordance with these policies.