Failure to Perform Hand Hygiene During Nephrostomy Tube Dressing Change
Penalty
Summary
The deficiency involves a failure to follow the facility’s infection prevention and control procedures during nephrostomy tube care for one resident. The facility’s policy for nephrostomy tube dressing changes specifies that after removing the soiled dressing and discarding it, staff must remove gloves, perform hand hygiene, and then don sterile gloves. During an observed nephrostomy tube dressing change for Resident #15, Nurse #3 donned a gown and gloves, removed the old dressing, discarded it, and cleansed the tubing and connection port with alcohol pads. After discarding the soiled items and removing her gloves, Nurse #3 immediately donned sterile gloves without washing her hands, and then applied a new sterile dressing to the nephrostomy tube insertion site. In interviews following the observation, Nurse #3 acknowledged that she should have washed her hands after removing the gloves used to change the old dressing and before putting on sterile gloves, stating she forgot but understood the importance of proper handwashing in infection control. The Infection Preventionist confirmed that hand hygiene should have been performed after removal of the old dressing and prior to donning sterile gloves and described hand hygiene as one of the most important steps in preventing infections. The NP caring for Resident #15 stated that the nurse should have washed her hands between handling the old dressing and applying the new dressing and explained that failure to follow this protocol put the resident at risk for introduction of bacteria to the ostomy site, which could cause infection. The DON stated that nurses changing any dressing should wash their hands before beginning, after removing the old dressing, before applying the new dressing, and after completing the dressing change, and confirmed that Nurse #3 did not follow this process.
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