Failure to Follow Hand Hygiene and Glove Change Protocols During Wound Care
Penalty
Summary
A deficiency was identified when a Treatment Nurse failed to follow proper infection prevention and control protocols during wound care for a resident. The nurse did not perform hand hygiene at several critical points, including after removing gloves and between glove changes, while providing wound care to the resident's sacral area and right heel. The nurse also failed to change gloves between different steps of the wound care process and when moving from one wound to another. These actions were observed during a wound care procedure, where the nurse handled wound dressings, applied treatments, and interacted with the resident and the environment without adhering to the facility's established hand hygiene and glove change policies. Interviews with the Treatment Nurse revealed a lack of routine hand hygiene between glove changes, despite having received training from the DON. The DON confirmed that staff are expected to perform hand hygiene before, during, and after care, and specifically after glove removal and between steps in wound care. Review of the facility's policies on wound care and hand hygiene further supported these expectations, outlining specific steps for handwashing and glove use to prevent infection and cross-contamination.