Failure to Perform Hand Hygiene During Pressure Ulcer Care
Penalty
Summary
A deficiency was identified when a treatment nurse failed to follow proper hand hygiene protocols during the care of a pressure ulcer for a resident. The facility's policy required hand hygiene and glove changes at specific steps during wound care, including after removing the old dressing, after cleaning the wound, and before applying a new dressing. However, during an observed dressing change for a resident with multiple complex medical conditions, the nurse did not remove gloves or perform hand hygiene at any of these required points. The resident involved had severe cognitive impairment and was totally dependent on staff for all activities of daily living. The resident's medical history included adult failure to thrive, long-term antibiotic use, anxiety disorder, functional quadriplegia, encephalopathy, MRSA infection, multiple contractures, and cognitive communication deficits. The nurse confirmed during an interview that she did not perform hand hygiene or change gloves as required during the wound care procedure. The DON also confirmed that the nurse had previously completed a skills checkoff on hand hygiene but failed to follow protocol during this incident.