Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by improper hand hygiene practices during wound care performed by an LVN. During wound care for a resident, the LVN did not consistently perform hand hygiene between glove changes, specifically after removing gloves and before donning new gloves while applying creams and dressings to the resident's lower extremities. The LVN did perform hand hygiene at the start of care and at certain points, but omitted it at several critical steps, contrary to facility policy and standard precautions. Interviews with the LVN revealed uncertainty regarding when hand hygiene should be performed during glove changes, while the DON stated that hand hygiene is expected before care, any time gloves are changed, and when hands are visibly soiled. Review of facility policies confirmed that hand hygiene is required immediately after glove removal and before moving from a soiled to a clean body site. The observed lapses in hand hygiene occurred during wound care for a resident with open areas on both lower extremities, as the LVN alternated between tasks without consistently following hand hygiene protocols.