Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
A deficiency was identified when a licensed practical nurse (LPN) failed to perform proper hand hygiene during wound care for a resident with moderate cognitive impairment and moisture-associated skin wounds. The resident's care plan required enhanced barrier precautions and specified that staff should don and doff personal protective equipment (PPE) according to protocol when providing high-contact care. During the observed wound care procedure, the LPN repeatedly changed gloves without sanitizing her hands between glove changes, despite handling both clean and dirty tasks. The LPN acknowledged not knowing that hand hygiene was required between glove changes. The director of nursing (DON) observed the procedure and confirmed that the LPN did not follow the facility's wound care treatment procedure, which directed staff to complete hand hygiene after removing gloves and before donning another pair. The DON stated that the expectation was to sanitize hands between glove changes and to change gloves between clean and dirty care. The facility's policy, as well as the resident's care plan, required these infection prevention measures, but they were not followed during the observed wound care event.