Failure to Follow Hand Hygiene and PPE Protocols During Wound Care
Penalty
Summary
The facility failed to implement and follow infection prevention and control guidelines during wound care for three residents. Observations revealed that the Wound Nurse did not consistently perform hand hygiene before and after glove removal, as required by facility policy. For example, during wound care for one resident, the nurse donned gloves without sanitizing or washing her hands, changed gloves multiple times without hand hygiene, and at times failed to wear a gown when enhanced barrier precautions were indicated. Supplies were also retrieved from outside the room without appropriate hand hygiene upon re-entry. In another instance, the Wound Nurse washed her hands and donned PPE at the start of wound care for a different resident but repeatedly changed gloves without performing hand hygiene between glove changes. The nurse was observed to be unaware of the requirement to perform hand hygiene every time gloves were removed, as confirmed during an interview. The Director of Nursing confirmed that hand hygiene should be performed before and after glove removal, in accordance with facility policy. A third resident's wound care was also observed with similar lapses. The Wound Nurse performed hand hygiene at the start and at certain points but failed to do so consistently between glove changes throughout the treatment of multiple wounds. The facility's hand hygiene policy, provided by the Director of Nursing, clearly stated that hand hygiene is required before and after glove removal, but this was not followed during the observed wound care procedures.