Failure to Perform Hand Hygiene During Pressure Ulcer Care
Penalty
Summary
A deficiency was identified when a nurse failed to perform proper hand hygiene during the treatment of multiple pressure ulcers for a resident. The resident, who was totally dependent on staff for all activities of daily living and had intact cognition, was admitted with several medical conditions including spondylolisthesis, neuromuscular dysfunction of the bladder, major depressive disorder, hemiplegia, and a history of urinary tract infection. Physician orders required specific wound care for five separate pressure ulcers, including cleansing, application of medihoney and calcium alginate with silver, and covering with dry dressings. During an observed wound care session, the nurse did not perform hand hygiene with alcohol-based hand rub or handwashing when changing gloves or between the care of each of the resident's five pressure ulcers. The nurse later confirmed in an interview that she did not perform hand hygiene during the wound care and believed it was only necessary between residents or if hands were visibly soiled. The Director of Nursing confirmed that hand hygiene should have been performed when changing gloves and between the care of each wound, but it was not done in this instance.