Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
A deficiency was identified when a nurse failed to follow proper infection prevention and control procedures during wound care for a resident. The nurse, after removing soiled dressings and cleansing a wound on the resident's right foot, changed gloves without washing or sanitizing her hands before applying a clean dressing. This action was observed during a wound care procedure and was not in accordance with the facility's hand hygiene policy, which requires hand hygiene after removing gloves and before moving from a contaminated to a clean body site. The resident involved was an elderly female with multiple diagnoses, including encephalopathy, congestive heart failure, hypothyroidism, and muscle weakness. Her care plan noted a risk of infection due to her tendency to pick at wounds, and she had a physician's order for daily wound care on her right foot. The nurse's failure to perform hand hygiene between glove changes during the wound care process was observed directly by surveyors. Interviews with the nurse, DON, and administrator confirmed that staff had been trained on infection control and handwashing procedures, and that the expectation was for hand hygiene to be performed when moving from dirty to clean surfaces, even when gloves are changed. The facility's policies on hand hygiene and infection prevention were reviewed and found to require these practices, which were not followed during the observed incident.