Failure to Follow Hand Hygiene Protocol During Wound Care
Penalty
Summary
A deficiency was identified when the Wound Nurse failed to follow the facility's Hand Hygiene policy during wound care for a resident. During an observation, the Wound Nurse donned a clean gown and gloves, removed the old dressing from the resident's left hip, sanitized her hands, and donned new gloves before cleaning the wound. However, after treating the left hip wound, the Wound Nurse did not remove her gloves or perform hand hygiene before proceeding to treat a second wound on the resident's right ankle. She applied skin prep to the right ankle while still wearing the same gloves used for the previous wound. The facility's policy requires hand hygiene and glove changes before moving from a soiled body site to a clean body site on the same resident. The Wound Nurse acknowledged during an interview that she did not sanitize her hands or change gloves between the two wound sites, attributing the lapse to being distracted by activity in the room. The Director of Nursing and Infection Preventionist confirmed awareness of the incident and stated their expectation for staff to follow infection control best practices. The Administrator also indicated that the Hand Hygiene policy should have been followed during wound care.