Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices related to wound care for one resident. The resident had multiple serious medical conditions, including paraplegia, a Stage 4 sacro-coccygeal pressure ulcer, bacteremia, immunodeficiency, and resistance to multiple antimicrobial drugs. The resident’s MDS showed severe cognitive impairment and dependence on staff for activities of daily living, and physician orders directed daily and as-needed wound care to the sacro-coccyx pressure injury, including cleansing with normal saline, patting dry, applying collagen powder and Thera honey, and covering with a foam dressing. During a wound care observation, the treatment nurse removed the resident’s soiled dressing and then continued the wound care procedure without changing gloves or performing hand hygiene, contrary to the facility’s Personal Protective Equipment policy. In interviews, the treatment nurse acknowledged she should have performed hand hygiene and donned a new pair of gloves after removing the dirty dressing and before continuing wound care. The DON also stated that gloves were intended for one-time use during removal of the soiled dressing and that the nurse should have removed the gloves, washed hands, and applied new gloves before proceeding, consistent with the written policy that gloves are single-use and that hands are to be washed before and after glove removal. The report stated these failures had the potential to increase the risk of infection for the resident and spread microorganisms to staff and other residents.
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