Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
A deficiency was identified when a nurse failed to follow proper infection prevention and control practices during wound care for a male resident with multiple complex medical conditions, including multiple myeloma, paraplegia, generalized muscle weakness, anxiety disorder, and a stage 4 sacral pressure ulcer. The resident's care plan required enhanced barrier precautions, including the use of gown and gloves during high-contact care activities such as wound care. During an observed wound care procedure, the nurse sanitized her hands before entering the room and donned appropriate personal protective equipment. However, she did not perform hand hygiene between glove changes while treating multiple wounds on the resident's body. Specifically, after removing gloves and before donning new ones to treat different wounds, the nurse failed to sanitize or wash her hands. This occurred multiple times during the procedure, including after removing dressings and before applying new ones to different wound sites. Additionally, after completing the wound care and removing her gloves, the nurse did not perform hand hygiene. Interviews with the nurse revealed she believed she usually sanitized her hands or washed them, but she did not acknowledge failing to do so during the observed care. Interviews with the ADON and DON confirmed that the facility's expectation and policy require staff to perform hand hygiene between glove changes and after glove removal, even if sinks are not available in every room, with hand sanitizer as an alternative. Review of the facility's hand hygiene policy further supported the requirement for hand hygiene before putting on gloves, when changing gloves, and immediately after removing gloves, especially after contact with wounds or contaminated materials.