Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) failed to consistently sanitize her hands between glove changes while providing wound care to a resident. The LVN was observed changing gloves multiple times during the wound care process, including after moving from dirty to clean areas and after touching environmental surfaces such as the bedside table and trash can, but did not perform hand hygiene between each glove change. The LVN later acknowledged during an interview that she did not sanitize her hands as required, attributing it to forgetting, and recognized that this could result in contamination during the glove changing process. The resident involved had multiple complex wounds, including a stage 3 pressure ulcer, a stage 4 pressure ulcer, and an unstageable pressure ulcer, with a care plan and physician orders specifying wound care procedures. The facility's policy and the LVN's competency checklist both required hand hygiene before donning gloves and after removing gloves. The Director of Nursing confirmed that the LVN should have sanitized her hands between glove changes and that failure to do so could result in the spread of germs.