Failure to Follow Hand Hygiene and PPE Protocols During Wound Care
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols during a dressing change for a resident under Enhanced Barrier Precautions (EBP). The wound nurse performed hand hygiene and donned gloves and a gown before starting the dressing change. However, after removing the initial wound dressing, the nurse changed gloves without performing hand hygiene in between. Following wound cleansing, the nurse removed their gown and gloves, exited the room, and did not perform hand hygiene before retrieving additional supplies from the treatment cart. Upon returning to the resident's room, the nurse performed hand hygiene and donned gloves but did not put on a gown before applying treatment and a new dressing to the wound. These actions were confirmed by the nurse during an interview. Review of facility policies and CDC guidelines indicated that hand hygiene should be performed before donning gloves, immediately after glove removal, and that gowns and gloves are required for high-contact activities such as wound care under EBP.