Failure to Follow PPE and Hand Hygiene Protocols During Wound Care
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) and hand hygiene during wound care for two residents on enhanced barrier precautions (EBP). For one resident with dementia, anemia, and venous/arterial ulcers, an LPN provided wound care without donning an isolation gown, despite EBP signage and care plan interventions requiring both gown and gloves for wound treatment. The LPN acknowledged not wearing the gown and was unaware it was required, even though training and signage were present. In a separate incident, another resident with a stage 3 pressure ulcer and osteomyelitis received wound care from staff who did not perform hand hygiene before donning PPE or between glove changes, as required by facility policy. During the wound care procedure, the LPN changed gloves without hand hygiene and applied a new glove with a contaminated hand, while the nurse aide also failed to perform hand hygiene before applying PPE. Both staff members were unable to clearly articulate the correct hand hygiene protocol during interviews. Facility policies for EBP and hand hygiene direct staff to perform hand hygiene before and after resident care, before donning PPE, and between glove changes, especially during high-contact activities such as wound care. Observations and interviews confirmed that these protocols were not followed during the wound care of both residents, resulting in a failure to implement the infection prevention and control program as required.