Failure to Follow Hand Hygiene Policy During Wound Care
Penalty
Summary
A deficiency occurred when the Unit Manager failed to follow the facility's Hand Hygiene policy during wound care for a resident. The Unit Manager was observed cleaning the bedside table, donning a clean gown and gloves, and removing the old dressing from the resident's sacrum. After doffing her gloves, she did not perform hand hygiene before donning new gloves and continued with the wound care procedure, including applying a collagen sheet and dry dressing. The Unit Manager also placed the soiled dressing onto the clean bedside table with wound care supplies instead of disposing of it in the trash can. She only washed her hands with soap and water after completing the procedure and before leaving the room. The facility's policy required hand hygiene immediately before touching a resident, before performing an aseptic task, after glove removal, and in other specified situations. The Unit Manager acknowledged during an interview that she was aware of the hand hygiene requirements and recognized her failure to sanitize her hands between glove changes. The Infection Preventionist and Director of Nursing both confirmed that the expectation was for staff to perform hand hygiene after glove removal and before donning new gloves, especially during wound care procedures.