Failure to Follow Hand Hygiene and Glove Change Protocols During Wound Care
Penalty
Summary
The facility failed to implement its infection prevention and control hand hygiene policy during wound care for two residents. The Wound Nurse did not change gloves or perform hand hygiene after completing wound care on one resident's buttocks wound, and proceeded to assess and treat a new area, as well as touch multiple surfaces and personal items, all while wearing visibly soiled gloves. The nurse continued to handle the resident's socks, heel protectors, bedding, call bell, and other room items before finally removing gloves and performing hand hygiene only at the end of the care episode. A similar failure occurred during wound care for another resident, where the Wound Nurse touched her gown and scrub pockets with gloved hands, left the room to retrieve scissors, and upon returning, performed wound care on two separate wounds. After completing care on the second wound, the nurse failed to remove gloves and perform hand hygiene before assisting the resident with mobility and clothing, and handling the resident's walker. Hand hygiene and glove removal were only performed at the conclusion of the care process. Interviews with the Infection Preventionist and the Director of Nursing confirmed that the facility's policy requires glove changes and hand hygiene between wound care tasks and after removing soiled gloves. The Wound Nurse acknowledged understanding of the policy and attributed the lapses to nervousness, stating she did not realize she had failed to change gloves or perform hand hygiene before touching multiple surfaces.