Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during wound care as required by its infection prevention and control program. A resident with severe cognitive impairment, bowel and bladder incontinence, dependence for all ADLs, and risk for pressure ulcers had physician orders for daily Calmoseptine application to a coccyx wound and daily cleansing and dressing of a right mid-back wound with Calcium Alginate, skin prep, and Mepilex. During an observed wound care procedure, an RN performed initial hand hygiene, donned PPE, sanitized the over-bed table, and set up a clean field with wound care supplies. While the resident was lying in bed on her right side, the RN loosened the incontinent brief, discovered a bowel movement, and provided perineal care with removal of the soiled brief while the DON assisted with placing a clean brief. After completing perineal care, the RN removed her gloves and donned a new pair without performing hand hygiene, then applied Calmoseptine ointment to the coccyx wound and finished applying the new brief. The RN again removed her gloves and donned another pair without hand hygiene before proceeding to the mid-back wound. With the same pair of gloves on, the RN and DON repositioned the resident, removed a dated dressing with blood-tinged drainage from the mid-back wound, sprayed wound cleanser on the wound bed and surrounding tissue, dabbed the area dry with 4x4 gauze, applied skin prep to the surrounding area, placed Calcium Alginate in the wound bed, and covered it with Mepilex. Interviews with the RN and DON confirmed that facility policy and staff training require hand hygiene with glove changes and after contact with body fluids, and policy documents specify hand hygiene after removing dirty gloves and between cleansing different wounds, which did not occur during this observed treatment.
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