Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
A wound care nurse (WCN) failed to perform proper hand hygiene after removing gloves and before providing wound care to a resident with multiple stage 4 pressure ulcers. Specifically, after sanitizing scissors, the WCN removed her gloves but did not sanitize her hands before donning new gloves and proceeding with wound care. The WCN later stated that she did not have her hand sanitizer in its usual location, which disrupted her routine, and she forgot to perform hand hygiene due to nervousness. The WCN acknowledged the importance of hand hygiene after glove removal to prevent infection and cross-contamination. The resident involved was an adult male with a history of stage 4 pressure ulcers on the sacrum and left big toe, type 2 diabetes, and hypertension. Physician orders required daily wound care, including cleaning and dressing changes. The facility's hand hygiene policy specified that hand hygiene should be performed immediately after glove removal. During interviews, the Director of Nursing (DON) confirmed that staff are expected to sanitize or wash hands for at least 30 seconds after glove removal, but could not recall when the last hands-on in-service for handwashing was conducted.