Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow proper hand hygiene protocols during a wound care procedure for a resident. The facility's policy requires staff to wash hands and change gloves at specific steps during wound care, including after removing old dressings and before applying new ones. During observation, the LPN washed her hands initially, but after removing gloves used to take off the resident's shoe and sock, she donned new gloves without sanitizing her hands. She then proceeded to remove the old dressing, cleanse the wound, and apply a new dressing without performing hand hygiene between glove changes as required by policy. The resident involved had been admitted with a diagnosis that included a hammer toe and developed a non-pressure, neuropathic wound on the dorsal aspect of the left second toe during her stay. Interviews with the LPN and the Director of Nursing (DON) confirmed that both were aware of the need for hand hygiene between glove changes and after touching items in the environment. The LPN acknowledged she should have sanitized her hands after touching the paper and the resident's shoes, and before continuing with the wound care procedure.