Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) failed to perform proper hand hygiene while providing wound care to a resident. During the observed wound care procedure, the LVN repeatedly changed gloves without cleansing her hands or using hand sanitizer between glove changes. The LVN acknowledged during the interview that she should have performed hand washing between glove changes but did not provide a reason for the omission. The Director of Nursing (DON), who also serves as the Infection Control Preventionist, confirmed that the expectation is for staff to sanitize hands between each glove change and that the LVN had previously been checked off on proper handwashing technique. The resident involved was an older adult male with a history of hypothyroidism and a moderately impaired cognitive status, as indicated by a BIMS score of 9. He had an open lesion on his right cheek, for which there was an active physician's order for daily wound care. The resident's care plan included interventions to maintain skin integrity and prevent infection. The facility's infection control policy required hand hygiene after removing gloves, but this protocol was not followed during the observed wound care procedure.