Failure to Follow Hand Hygiene Protocol During Wound Care
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow the facility's infection prevention and control policy during wound care for a resident with impaired skin integrity and multiple surgical wounds. The facility's policy required hand hygiene to be performed before and after glove use. During an observed wound care procedure, the LPN donned a gown and gloves, removed the resident's soiled right heel dressing with scissors, and proceeded to cleanse the wound and apply new dressings without removing her gloves or performing hand hygiene between the removal of the old dressing and the application of the new one. The resident involved had a care plan for impaired skin integrity and physician's orders for daily wound care, including cleansing and dressing changes. The LPN confirmed during an interview that she did not change gloves or sanitize her hands after removing the soiled dressing and before performing clean wound care. The Director of Nursing also confirmed that the correct procedure would have been to remove gloves, sanitize hands, and don new gloves before continuing with the wound care.