Failure to Maintain Hand Hygiene During Wound Care
Penalty
Summary
A deficiency occurred when a nurse failed to maintain proper hand hygiene during wound care for a male resident with two stage 4 pressure ulcers. The resident, who had severe cognitive impairment and a history of pressure injuries, required daily wound care as per physician orders. During an observed wound care procedure, the nurse washed her hands in the resident's bathroom but then touched the privacy curtain and door handle with her bare hands before donning gloves and continuing wound care. This sequence of actions was observed twice during the same procedure, once for each wound. The facility's infection control policy required hand hygiene before and after resident care, after contact with potentially contaminated surfaces, and after removing gloves. The nurse did not use hand sanitizer or rewash her hands after touching potentially contaminated surfaces before resuming wound care. Both the nurse and the Director of Nursing acknowledged during interviews that this practice could result in the transfer of germs to the resident, which is inconsistent with the facility's infection control protocols.