Failure to Follow Hand Hygiene Protocols During Wound Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during wound care for a resident who was on enhanced barrier precautions due to a stage IV pressure ulcer and additional skin tears. During a wound care procedure, both the LVN and the DON initially washed their hands and donned gowns and gloves. However, the DON touched non-sterile surfaces, including a window blind, bed controls, and bed linens, and then proceeded to provide direct care to the resident without changing gloves or washing her hands. The LVN, after removing soiled gloves, walked to the treatment cart, obtained clean gloves, and donned them without performing hand hygiene in between. Both staff members acknowledged during interviews that they did not follow proper hand hygiene protocols as outlined in the facility's policy and their training. The resident involved was non-responsive during the procedure and had a significant medical history, including Parkinsonism and a stage IV pressure ulcer requiring daily wound care. The failure to perform hand hygiene at appropriate times during wound care was observed and confirmed by both staff members involved.