Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control policy during wound care for a resident with a history of peripheral vascular disease and an unstageable pressure ulcer. During an observed dressing change, the registered nurse did not perform hand hygiene between glove changes at multiple points in the procedure, despite the facility's policy requiring hand washing after glove removal and before donning new gloves. The nurse removed gloves and immediately put on new gloves several times without washing hands, including after removing soiled dressings and before handling clean supplies and applying new dressings. The resident involved had moderate cognitive impairment and a large, deep unstageable wound on the sacrum. The nurse's actions were observed and later confirmed in interviews, where both the nurse and the Director of Nursing acknowledged that hand hygiene should have been performed between glove changes. The facility's policy, which was reviewed, clearly outlined the steps for hand hygiene during wound care, but these were not followed during the observed incident.