Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
During a wound care procedure for a resident with multiple pressure ulcers, including a stage 4 sacral pressure wound and other significant comorbidities such as osteomyelitis and diabetes, a registered nurse failed to follow established infection prevention and control protocols. Specifically, after cleansing the wound and applying calcium alginate, the nurse did not change gloves or perform hand hygiene before placing a new border dressing on the wound. This action was observed by a surveyor, who noted that the nurse had come into contact with the wound and its exudate prior to applying the clean dressing, thereby not adhering to both facility policy and CDC guidelines for hand hygiene during wound care. Facility policies require hand hygiene before and after wound care, after glove removal, and when moving from a soiled to a clean body site. The CDC also recommends hand hygiene immediately before touching a patient, after contact with blood or body fluids, and after glove removal. The nurse's failure to perform hand hygiene at the appropriate step during the dressing change was confirmed through observation and staff interviews, which indicated that staff are expected to follow these protocols during wound care procedures.