Failure to Follow Hand Hygiene Protocols During Wound and Perineal Care
Penalty
Summary
The facility failed to provide perineal and wound care in a manner that prevents the spread of infection for two of five observed care events involving a resident with multiple diagnoses, including contracture of muscle and essential hypertension, and severely impaired cognition. During wound care, the registered nurse did not perform hand hygiene after initiating the procedure, and the certified nursing assistant did not sanitize hands before applying clean gloves after returning to the room to assist with perineal care. Both staff members acknowledged their lapses in hand hygiene, with the CNA admitting to forgetting to wash hands and the RN confirming failure to perform hand hygiene at each step of the wound care process, including after cleansing, drying, applying collagen, and dressing the wound. Interviews with the infection preventionist and the director of nursing confirmed that both staff members did not follow facility policies regarding hand hygiene and glove changes during wound and perineal care. The facility's policies require hand hygiene before and after care, as well as glove changes and hand sanitization at each phase of wound care. The staff's failure to adhere to these protocols placed the resident at risk for wound and urinary tract infections, as confirmed by the facility's leadership during interviews.