Failure to Follow Hand Hygiene and Wound Care Orders During Pressure Ulcer Treatment
Penalty
Summary
The facility failed to follow proper hand hygiene and glove-changing protocols during wound care for a resident with stage three pressure ulcers on the right thigh and right heel. During observed wound care, a registered nurse removed old dressings, changed gloves without performing hand hygiene, and proceeded to clean and dress both wounds without changing gloves or sanitizing hands between dirty and clean procedures or between each wound. The nurse confirmed awareness of the correct protocol but did not follow it during the treatment. The facility's wound care policy requires hand hygiene and glove changes between dirty and clean steps and between different wound treatments, which was not adhered to in this instance. Additionally, the facility failed to administer physician-ordered wound treatments as scheduled. Documentation showed that the resident's prescribed wound care for the right heel and right posterior thigh was not completed on two evening shifts. The resident reported that wound treatments were sometimes missed by nursing staff, and the Director of Nursing confirmed that the treatments were not signed out for the specified shifts, indicating they were not performed as ordered.