Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
A deficiency was identified when a staff member failed to perform hand hygiene during wound care for a resident with quadriplegia and multiple pressure ulcers. The resident had a history of four pressure ulcers upon admission and later developed an additional in-facility pressure ulcer. During observed wound care procedures, the LPN was seen removing and donning new gloves multiple times while providing care to wounds on the ischium and sacrum, but did not perform hand hygiene between glove changes as required by CDC guidelines. The LPN acknowledged performing hand hygiene only before and after the wound care treatments, not in between glove changes. The Director of Nursing Services confirmed that the expectation was for staff to perform hand hygiene after glove removal during wound care. This failure to follow proper hand hygiene protocol was observed and confirmed through staff interview and record review.