Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during wound care for one resident. During an observed wound care procedure, the treatment nurse did not perform hand hygiene between glove changes or after removing gloves, despite handling various supplies and touching the resident's wound. The nurse also did not use hand sanitizer prior to entering the resident's room or after removing gloves at several points during the procedure. The nurse handled items such as a tube of medicated ointment, gauze, dressings, and a marker without performing hand hygiene between tasks, and only washed her hands at the end of the procedure after disposing of trash. The resident involved was an elderly male with a history of a left femur fracture, hypertension, and chronic kidney disease, and had a pressure wound on his left heel. The resident had severely impaired cognition and required wound care as part of his treatment plan. The facility's infection control policy required hand hygiene before and after changing dressings and after removing gloves, but these protocols were not followed during the observed wound care event.