Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain proper infection control practices during wound care for one of four sampled residents. Specifically, a treatment nurse did not perform hand hygiene between glove changes while providing wound care to a resident with a Stage 4 pressure injury in the sacral region. The nurse was observed removing the old dressing, cleansing the wound, and changing gloves multiple times without performing hand hygiene in between. Additionally, the nurse placed scissors used for dressings on a waterproof barrier pad on the resident's bed and later on a table, without cleaning them before placing them with clean materials. The nurse also did not perform hand hygiene after discarding used dressings and before continuing with other care tasks. The resident involved had severely impaired cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 0 out of 15, and was on enhanced barrier precautions. The physician's order required specific wound care procedures, including cleansing, packing, and dressing the wound. The facility's policy on hand hygiene, dated March 2024, required staff to decontaminate hands before and after patient contact, before donning gloves, before moving from a contaminated to a clean body site, and after removing gloves. Both the treatment nurse and the Director of Nursing acknowledged that hand hygiene should have been performed between glove changes, as per facility policy.