Failure to Perform Hand Hygiene During Wound Dressing Change
Penalty
Summary
The facility failed to prevent potential cross contamination during a wound dressing change for a resident with pressure ulcers. According to the facility's wound dressing change policy, hand hygiene is required at multiple steps, including after removing the old dressing and before applying a new one. During an observed dressing change, an LPN cleansed the resident's coccyx wound and applied a new dressing without washing hands after removing the soiled dressing, contrary to the established protocol. The LPN later confirmed not performing hand hygiene during the procedure. The resident involved had a history of cellulitis of the left lower limb, anxiety, osteoarthritis of the knee, and diabetes mellitus. The Director of Nursing confirmed in an interview that hand hygiene should be performed several times during a wound dressing change to ensure proper infection control and prevent cross contamination. The failure to follow hand hygiene protocols during the dressing change constituted a deficiency in infection prevention and control practices.