Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own hand hygiene policies during wound care for Resident #10. The facility’s Hand Hygiene and Basics of Hand Hygiene policies require staff to perform hand hygiene before applying and after removing PPE such as gloves, and before and after providing any type of care. During an observed wound care session, the Wound Nurse prepared supplies on a disinfected over-bed table with a protective barrier, washed her hands, and donned a gown and gloves before starting treatment. As the resident was positioned on her right hip to expose a left hip wound, the Wound Nurse removed the soiled dressing, removed her gloves, and then applied clean gloves without performing hand hygiene. She then cleansed the wound, applied skin prep, removed her gloves, sanitized her hands, and applied clean gloves before placing a foam dressing. After that, she again removed her gloves but did not perform hand hygiene before putting on another pair of clean gloves. The resident was then repositioned to expose sacral and right hip wounds. For the sacral wound, the Wound Nurse removed the dirty dressing, removed her gloves, and performed hand hygiene before donning clean gloves and cleansing the wound. She then removed her dirty gloves and again applied clean gloves without performing hand hygiene, applied soaked gauze and a foam dressing, then removed her gloves and performed hand hygiene before donning clean gloves. For the right hip wound, the Wound Nurse removed the dirty dressing, removed her gloves, and washed her hands before applying clean gloves and cleansing the wound. She then removed her dirty gloves and applied clean gloves without performing hand hygiene, applied soaked gauze and a foam dressing, and finally removed her gloves and performed hand hygiene. In interviews, the Wound Nurse acknowledged she did not realize she had failed to perform hand hygiene between some glove changes, stated she knew she was supposed to, and attributed the lapses to losing track due to multiple glove changes and being nervous under observation. The Infection Preventionist and Administrator both confirmed that facility policy and expectations require hand hygiene every time gloves are removed, regardless of visible soiling.
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