Failure to Perform Proper Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene and infection control practices during wound dressing changes for a resident. During the observed dressing change, a CNA handled a used coffee cup that the resident had used as a urinal and placed it on the bedside table. Multiple lapses in hand hygiene were observed by an LPN, including changing gloves without hand sanitization, washing hands for less than the required fifteen seconds, turning water on and off with bare hands, and applying wound care products without proper hand hygiene. The LPN also exited and re-entered the room in PPE, put on new gloves without sanitizing hands, and failed to change gloves after removing a dressing. The CNA also assisted with dressing changes without reapplying new gloves after handling soiled linens. Review of the facility's hand hygiene policy revealed that staff are required to wash hands for at least fifteen seconds after removing gloves, handling soiled items, and before donning new gloves. The policy also specifies the use of alcohol-based hand rubs when hands are not visibly soiled and outlines proper procedures for handwashing, including turning off faucets with a clean paper towel. The observed practices did not align with these policy requirements, resulting in a failure to maintain appropriate infection prevention and control measures during resident care.