Failure to Perform Proper Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by improper hand hygiene during wound care for a resident. During an observed wound care procedure, a registered nurse performed hand hygiene initially and donned gloves and a gown before removing the resident's old bandage. However, after removing gloves at multiple points during the procedure, the nurse did not perform hand hygiene before donning new gloves, contrary to facility policy and physician orders. The nurse continued the wound care process, including cleansing and dressing the wound, without appropriate hand hygiene between glove changes. Interviews with the nurse and the Director of Nursing confirmed that hand hygiene should have been performed after each glove removal, and both acknowledged that this was not done during the observed procedure. The facility's policies on clean dressing changes and hand hygiene specifically require handwashing after glove removal to prevent infection and cross-contamination, but these protocols were not followed during the care of the resident with a left knee wound.