Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
During wound care treatment for one resident, an LPN failed to perform hand hygiene between glove changes as required by facility policy. The facility's hand hygiene policy, revised in October 2022, specifies that staff must use an alcohol-based hand rub or soap and water before handling clean or soiled dressings, before moving from a contaminated to a clean body site, after handling used dressings and contaminated equipment, and after removing gloves. Observation revealed that the LPN washed hands and donned gloves and a gown at the start of the procedure, but subsequently removed gloves and donned new ones multiple times without performing hand hygiene in between. This sequence occurred while providing wound care to the resident's posterior thighs and right posterior heel. The LPN confirmed in an interview that hand hygiene was not performed between glove changes and acknowledged that it should have been done.