Failure to Perform Proper Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed during wound care for two residents who required extensive assistance with bed mobility and personal hygiene. For both residents, the infection preventionist (IP) did not remove gloves and perform hand hygiene after cleansing wounds and before applying new dressings, as observed during dressing changes. The IP initially sanitized or washed hands and donned appropriate personal protective equipment before starting the procedures, but did not follow hand hygiene protocols between the removal of soiled dressings, cleansing of wounds, and application of clean dressings. Interviews with the IP and the interim director of nursing confirmed that facility policy and expectations required staff to perform hand hygiene before and after handling dressings, and specifically after removing soiled dressings and cleansing wounds. The facility's hand hygiene policy, reviewed in February 2025, also indicated that hand hygiene should be completed before and after handling clean or soiled dressings and when moving from a contaminated to a clean body site. The IP acknowledged not following these procedures during the observed wound care for both residents.