Failure to Follow Hand Hygiene Protocol During Wound Care
Penalty
Summary
Nurse #2 failed to follow the facility's Hand Hygiene policy during a wound care procedure for a resident with multiple wounds. After removing the old dressings from two wounds on the resident's lower back and sacrum, Nurse #2 doffed her gloves, sanitized her hands, and donned clean gloves before cleaning and dressing the first wound. However, she did not change gloves or sanitize her hands before proceeding to clean and dress the second wound on the sacrum, instead using the same gloves for both wounds. This action was observed by the Infection Preventionist, who was assisting during the procedure. The facility's policy requires hand hygiene and glove changes before moving from a soiled to a clean body site and between different wounds on the same resident. Nurse #2 acknowledged during an interview that she was aware of the missed hand hygiene and glove change between the two wounds, attributing the lapse to nervousness during the procedure. The Infection Preventionist and Director of Nursing both confirmed that the expectation is for staff to perform hand hygiene and change gloves between wound sites, as outlined in the facility's infection control policy.