Failure to Ensure Proper Hand Hygiene During Wound Care
Penalty
Summary
A deficiency was identified in the facility's infection prevention and control program related to improper hand hygiene during wound care for a resident with multiple lower limb wounds, including cellulitis, chronic ulcers, and deep tissue injuries to both heels. The resident required significant assistance with mobility and had physician orders for daily wound care on both heels. During an observed wound care procedure, an LPN failed to perform hand hygiene between glove changes after removing soiled dressings and before cleansing and dressing the wounds. Specifically, the LPN removed gloves and donned new gloves multiple times without performing hand hygiene, despite being interrupted and acknowledging the correct procedure. Further interviews with facility leadership, including the Director of Nursing Services and the Infection Preventionist, confirmed that hand hygiene should be performed before care, with each glove change, and after care is complete. Review of the facility's policy also indicated that staff are required to wash or sanitize hands after removing soiled dressings and before applying clean dressings. The observed failure to follow these protocols during wound care led to the identified deficiency.