Failure to Follow Hand Hygiene Protocol During Wound Care
Penalty
Summary
During wound care for a resident with a coccyx wound, a nurse aide (NA) failed to follow the facility's hand hygiene policy. After removing the resident's dressing, the NA did not remove her gloves, perform hand hygiene, and don clean gloves before proceeding to clean the wound with normal saline-soaked gauze and then drying the wound. The NA only removed her gloves, washed her hands, and donned clean gloves after cleaning and drying the wound, just prior to assisting with the application of a wound vac. The facility's policy requires staff to perform hand hygiene before and after handling clean or soiled dressings and after removing gloves. Both the NA and the nurse assisting in the procedure believed the wound care had been performed correctly at the time. However, upon later interview, the NA acknowledged the oversight and confirmed knowledge of the correct procedure. The infection preventionist and administrator both confirmed that the NA should have doffed gloves, sanitized hands, and donned clean gloves after removing the dressing and before cleaning the wound.