Failure to Perform Hand Hygiene During Dressing Change
Penalty
Summary
A deficiency was identified when a nurse failed to perform proper hand hygiene during a dressing change for a resident. The resident, who was cognitively intact and dependent on staff for activities of daily living, had multiple diagnoses including COPD, chronic kidney disease stage four, ventilator dependence, and anxiety. The physician's order required wound care to the right lower abdomen, including cleansing with normal saline, application of collagen, and covering with a foam dressing. During observation, the nurse gathered supplies, prepared the area, and performed the dressing change, but did not wash or sanitize hands after removing soiled gloves and before donning clean gloves on four separate occasions throughout the procedure. Interview with the nurse confirmed that hand hygiene was not performed between glove changes, despite facility policy requiring hand washing or sanitizing after glove removal and before donning new gloves during dressing changes. Review of the facility's policy outlined specific steps for hand hygiene at multiple points during the dressing change process, which were not followed in this instance. The failure to adhere to these procedures was observed and verified through record review, observation, interview, and policy review.