Improper Hand Hygiene During Wound Dressing Change
Penalty
Summary
The facility failed to ensure proper hand hygiene during a dressing change for Resident #8, who was admitted on 07/18/22 with diagnoses including metabolic encephalopathy, acute osteomyelitis, paraplegia, and a sacral pressure ulcer injury. During an observation on 01/05/26 at 2:15 P.M., LPN #210 donned gloves, gown, and mask, assisted the resident to roll to the right side, and exposed bilateral ischium wounds that were covered with bordered dressings, with a small amount of brownish discharge noted on the protective pad. After touching the drainage, LPN #210 removed gloves, performed hand hygiene, and donned new gloves, then removed the soiled dressings. Without performing additional hand hygiene or changing gloves, LPN #210 proceeded to clean the wounds with wound cleanser, apply skin prep to the surrounding tissue, and place new dressings on both wounds. In a post-procedure interview, LPN #210 confirmed that she had not changed gloves or performed hand hygiene between handling soiled materials and performing clean wound care, which was inconsistent with the facility’s written policy requiring handwashing with soap and water after removing old dressings and application of new clean gloves for continued care. This deficiency was cited under the requirement to provide and implement an infection prevention and control program and was investigated under Complaint Number 2670977.
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