Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
A deficiency was identified when an LPN failed to perform required hand hygiene during the provision of wound care to a resident with severe cognitive impairment and total dependence for activities of daily living. The resident, who was on hospice care for dementia and had a stage 3 pressure injury, was observed during a wound treatment procedure. The facility's hand hygiene policy requires hand hygiene before and after resident contact, after glove removal, and before performing aseptic tasks. However, the LPN did not perform hand hygiene after cleaning up an incontinence episode, after removing gloves, or before proceeding with wound care and dressing changes. During the observed procedure, the LPN washed hands and donned gloves before touching the resident, but subsequently failed to perform hand hygiene at multiple required points, including after removing soiled gloves and before handling the wound and dressing supplies. The LPN continued to change gloves and handle both the wound and the resident's environment without performing hand hygiene as outlined in the facility's policy. The deficiency was confirmed through observation, interview, and record review.