Failure to Follow Hand Hygiene and Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to follow its own Hand Hygiene and Enhanced Barrier Precautions (EBP) policies and procedures during wound care for two residents. Observations revealed that the Wound Nurse did not don a gown, change gloves, or perform hand hygiene at required points during wound care procedures. Specifically, after removing soiled dressings and after cleansing wounds, the Wound Nurse did not change gloves or sanitize hands before applying new dressings. These lapses were observed during wound care for a resident with an unstageable right heel pressure ulcer and another resident with a diabetic foot ulcer. The Wound Nurse acknowledged during interviews that she did not follow proper glove changing and hand hygiene protocols, stating she "just forgot" to perform these steps. She also did not wear a gown during the procedures, explaining that she had questioned the need for EBP with the Assistant Director of Nursing (ADON), who advised that EBP was not required for these residents. The nurse was unaware that EBP should be used for open, draining wounds regardless of their chronicity or expected healing time. Interviews with the Infection Preventionist (IP) and Director of Nursing (DON) revealed a misunderstanding of CDC guidelines regarding EBP. Both believed that EBP was only necessary for wounds present for six months or longer, and therefore did not implement EBP for the residents in question. The IP and DON were informed during the survey that EBP should be applied to any open, draining wounds, not just chronic wounds, and acknowledged the need to reevaluate their practices.