Failure to Follow Hand Hygiene and Glove Change Protocols During Wound Care
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to follow standard and transmission-based precautions during wound care for a resident with multiple medical conditions, including respiratory failure, diabetes mellitus, and a laceration on the left lower leg. The resident was under Enhanced Barrier Precautions (EBP) and required daily wound care as per physician's orders. During an observed dressing change, the LVN wore a gown and gloves, removed the soiled bandage, but did not change gloves or perform hand hygiene before proceeding to clean the wound and apply new treatment and dressings. The LVN later acknowledged not changing gloves or performing hand hygiene as required. Interviews with the infection preventionist and the director of nursing confirmed that facility policy and training require staff to change gloves and perform hand hygiene when transitioning from a soiled to a clean procedure during wound care. The facility's wound care policy also outlines these steps, emphasizing glove changes and hand hygiene to prevent infection. The failure to adhere to these protocols was observed and confirmed through staff interviews and record reviews.