Failure to Follow Hand Hygiene Protocol During Wound Care
Penalty
Summary
A Registered Nurse (RN) failed to follow proper hand hygiene protocols during a wound dressing change for a resident. The RN entered the resident's room, performed initial hand hygiene, and applied gloves. After removing the soiled dressing from the resident's left second toe, the RN, without changing gloves, used the same soiled gloves to handle clean gauze, apply wound cleanser, open ointment, and apply ointment to the wound. The RN also attempted to apply a bandaid with the same soiled gloves before finally removing them and performing hand hygiene. The facility's policy on hand hygiene, revised in August 2019, requires staff to change gloves and perform hand hygiene at specific points during wound care, including after handling soiled dressings and before handling clean supplies. The Director of Nursing (DON) confirmed in an interview that the RN should have changed gloves during the dressing change. The failure to change gloves and perform hand hygiene as required resulted in a breach of infection control practices for one of two residents observed during wound care.