Failure to Perform Hand Hygiene After Dressing Change
Penalty
Summary
A deficiency was identified when a Physician's Assistant (PA) failed to perform proper hand hygiene during a dressing change for a resident with an unstageable pressure ulcer on the coccyx. The PA donned gloves and conducted a wound assessment and debridement using a disposable scalpel. After completing the procedure, the PA removed the soiled gloves but did not sanitize or wash their hands before handling the used scalpel with bare hands, placing it inside a removed glove, and then touching personal items and the room's door knob. The PA confirmed in an interview that hand hygiene was not performed after glove removal. The facility's hand hygiene policy specifically requires hand hygiene immediately after removing gloves, and this incident represents a repeat deficiency from a previous survey.