Failure to Follow Hand Hygiene During Wound Care
Penalty
Summary
Facility staff failed to adhere to proper hand hygiene practices during wound care for one resident. During an observation of sacral pressure ulcer care, an LPN, assisted by a CNA, performed wound cleansing and dressing changes. After cleaning the wound and before handling clean wound care supplies, the LPN did not remove her gloves or wash or sanitize her hands, as required by infection prevention protocols. This lapse was acknowledged by the LPN during an immediate post-procedure interview. The resident involved had a history of atrial fibrillation, diabetes, and hypertension, and was cognitively intact at the time of the incident. The wound care procedure required the use of clean gloves and hand hygiene between handling soiled and clean supplies, but these steps were not followed, as directly observed by surveyors.