Failure to Perform Proper Hand Hygiene During Wound Care
Penalty
Summary
A deficiency was identified when a wound care nurse (WCN) failed to perform proper hand hygiene before and after providing wound care to a resident. Specifically, the WCN washed her hands for approximately 9 seconds prior to wound care and for about 18 seconds after completing the procedure, both of which were less than the facility's policy requirement of at least 20 seconds. The resident involved was an elderly female with multiple diagnoses, including Alzheimer's disease, dementia, cerebral infarction, chronic atrial fibrillation, and hypertension, and had a stage four pressure injury to the coccyx requiring daily wound care as ordered by her physician. Interviews with the WCN, Director of Nursing (DON), and Staff Development Nurse confirmed that staff are expected to perform hand hygiene for a minimum of 20 seconds, using methods such as singing "Happy Birthday" twice or counting to 20 seconds to ensure thorough cleaning. The facility's hand hygiene policy and procedure forms also specify a minimum of 20 seconds for handwashing. Despite recent competency checks indicating no concerns, the WCN did not meet the required hand hygiene duration during the observed wound care procedure.