Failure to Follow Hand Hygiene Protocol During Wound Care
Penalty
Summary
A deficiency was identified when a Treatment Nurse failed to follow the facility's Hand Hygiene policy during wound care for a resident. The nurse was observed performing wound care procedures, including cleaning and dressing two wounds, but did not sanitize her hands each time after removing gloves and before donning new gloves, as required by policy. The nurse washed her hands at the start and end of the procedure but neglected to perform hand hygiene between glove changes, even after handling soiled dressings and before touching clean supplies and the resident's wounds. The nurse acknowledged during an interview that she was aware of the hand hygiene requirements but attributed her lapses to nervousness during the observation. The Infection Preventionist and Director of Nursing both confirmed that the expectation is for staff to sanitize hands after each glove removal and before putting on new gloves during wound care. The incident was observed during a wound care session for a resident with wounds on the left thigh, and the nurse's failure to perform proper hand hygiene was directly witnessed by surveyors.