Failure to Perform Hand Hygiene During Wound Care on EBP Resident
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for one resident who was on Enhanced Barrier Precautions (EBP) due to a Stage Two Pressure Injury on the left ischium. According to the facility's own hand hygiene policy, staff are required to perform hand hygiene before handling dressings, after contact with a resident's skin, and after removing gloves, with the use of alcohol-based hand rub (ABHR) or soap and water. During a wound care observation, the nurse responsible for the resident's care donned a gown and gloves, entered the room, and prepared the work surface and supplies. However, the nurse did not perform hand hygiene between glove changes at multiple points during the wound care procedure, specifically after removing soiled gloves and before donning new gloves, despite handling the resident's wound and dressing supplies. The nurse acknowledged after the observation that she did not cleanse her hands between glove changes and recognized that this failure could contribute to the spread of germs. The Infection Preventionist confirmed that all staff were educated on hand hygiene and that the nurse should have cleaned her hands between glove changes to prevent the transmission of organisms. The deficiency was identified through direct observation, interviews, and review of facility policies and the resident's care plan and physician orders, all of which emphasized the importance of hand hygiene in infection control, especially for residents on EBP.