Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
During a wound care procedure for a resident, the wound care nurse sanitized her hands and donned a gown and gloves before beginning the dressing change. After removing the resident's right foot dressing and disposing of it in a biohazard bag, the nurse removed her gloves and immediately put on a new pair without performing hand hygiene. This process was repeated after cleaning the wound with normal saline, as the nurse again changed gloves without sanitizing her hands in between. Interviews with the wound care nurse, the infection preventionist, and the director of nursing confirmed that hand hygiene should have been performed between glove changes during the dressing change. The facility's policies on universal precautions and handwashing technique require handwashing before and after each resident contact and during duties such as handling dressings, regardless of glove use. The failure to perform hand hygiene between glove changes was observed and acknowledged by staff.