Failure to Follow Hand Hygiene and Glove-Change Protocol During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policy during wound care for three residents. The facility’s policy, revised on 10/28/24, required staff to perform hand hygiene before and after donning gloves, to change gloves when moving from dirty to clean tasks, and to always change gloves between residents. During wound care for Resident #4, the Treatment Nurse was observed with a gown already on, sanitized her hands, and donned clean gloves. The dressing had already come off earlier during incontinence care. She cleaned the coccyx pressure ulcer with gauze soaked in wound cleaner and, without changing gloves or performing hand hygiene, applied Santyl ointment, wet-to-moist Dakin’s solution, packed the wound bed, and applied a super absorbent pad before discarding supplies and removing PPE. During wound care for Resident #62, the Treatment Nurse donned a clean gown and gloves, removed the old dressing from the resident’s right ankle, and cleaned the wound with gauze soaked in wound cleaner. While still wearing the same gloves used for cleaning, she applied an axeroform petrolatum dressing to the wound. She then collected and discarded the supplies, removed her gown and gloves, and washed her hands with soap and water only after the entire procedure was completed, without an interim glove change or hand hygiene between the dirty and clean portions of the wound care. For Resident #103, the Treatment Nurse entered the room wearing a gown, washed her hands, and put on gloves before removing the dressing from a right heel pressure ulcer. She then removed her gloves, used hand sanitizer, donned new gloves, and cleaned the ulcer with gauze soaked in wound cleaner. Without removing gloves or performing hand hygiene, she patted the ulcer dry with gauze, applied collagenase ointment with a cotton swab, covered the wound with calcium alginate and an abdominal pad, and wrapped the foot. After removing gloves and using hand sanitizer, she donned new gloves and removed the dressing from a surgical wound with staples on the resident’s left foot, then again removed gloves, sanitized her hands, and applied new gloves before cleaning the wound. She proceeded to cover the left foot wound with an abdominal pad and wrap it with gauze without changing gloves or performing hand hygiene between cleaning and dressing application. In interviews, the Treatment Nurse, Infection Preventionist, and DON all acknowledged that gloves should have been changed and hand hygiene performed between cleaning the wounds and applying clean dressings for all three residents.
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