Failure to Follow Hand Hygiene and Wound Care Protocols During Resident Wound Care
Penalty
Summary
Staff failed to follow proper infection prevention and control procedures during wound care for one resident with a pressure wound to the right heel, who also had diagnoses including asymptomatic HIV infection, acute kidney failure, and anxiety disorder. During an observed wound care procedure, the Wound Care Nurse did not perform hand hygiene after removing the soiled dressing and before donning new gloves. The soiled dressing was rolled up in the right hand glove, disposed of, and a new glove was put on without handwashing. The nurse then proceeded to cleanse the wound. Additionally, the Registered Nurse/MDS Nurse assisting with the procedure placed the resident's cleansed foot back onto a soiled absorbent pad before picking it up again at the Wound Care Nurse's request. The clean wound dressing was then applied without re-cleansing the wound. Both nurses acknowledged during interviews that proper hand hygiene and wound care protocols were not followed, and facility leadership confirmed their expectations for adherence to these policies.