Failure to Follow Hand Hygiene and Aseptic Technique During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to follow proper infection prevention and control practices during wound care for a resident. During an observed wound care procedure, an LPN did not perform hand hygiene before opening the treatment cart, touching wound care supplies, or bringing those supplies and the physician’s wound care order into the resident’s room. The LPN placed wound care supplies and wound care scissors on the resident’s bedside table without sanitizing the table surface or the scissors. The LPN then donned gloves without prior hand hygiene and removed the resident’s soiled wound dressing, which had yellow discharge. With the same soiled gloves, the LPN opened a bottle of sterile saline and set it on the unclean bedside table, again without performing hand hygiene. After handling the saline bottle, the LPN removed the soiled gloves but did not perform hand hygiene before reaching into a box of clean gloves and donning a new pair. The LPN then poured saline on gauze to clean the resident’s open wound and picked up the unsanitized scissors from the soiled bedside table to cut antimicrobial dressing material, which was placed directly onto the open wound. The LPN did not sanitize the scissors before using them to prepare the dressing. The LPN continued the wound care by applying ointment, a foam-covered bandage, an ace wrap, and a hard plastic brace, and then used the same unsanitized scissors to cut off Velcro from another ace bandage applied over the brace and the resident’s arm. These actions occurred despite CDC guidance that failure to perform appropriate hand hygiene is a leading cause of health-care-associated infections and spread of multiresistant organisms.
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