F0880

D

Failure to Perform Hand Hygiene Between Glove Changes During Wound Care

Marietta, Georgia Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves failure to follow appropriate hand hygiene practices during wound care for a resident with a Stage IV sacral pressure ulcer. The resident’s EMR showed multiple diagnoses including late-onset Alzheimer’s disease, severe dementia, paraplegia, peripheral vascular disease, underweight/low BMI, dysphagia, and a Stage IV sacral pressure ulcer. The care plan included interventions to reduce risk of complications and infection, such as weekly wound assessments, ordered treatments, use of a low-air-loss mattress, positioning/off-loading devices, maintaining cleanliness and dryness, enhanced barrier precautions, nutritional support, and coordination with hospice and the wound provider. Wound provider documentation shortly before the observation described the sacral pressure injury as Stage IV, with mild serous drainage, no odor, no peri-wound erythema, and noted the wound as improving.

During an observed wound care procedure, the LPN wound care nurse donned gloves and removed the soiled dressing, then removed those gloves and put on a new pair without performing hand hygiene between glove removal and re-gloving. After cleansing the wound per treatment order, the LPN again removed and replaced gloves without performing hand hygiene between glove changes. The dressing was then applied, the resident was repositioned, and the soiled dressing was removed from the room. In an interview following the observation, the LPN stated she was unaware that hand hygiene was required between removing and donning new gloves during wound care. In a separate interview, the RN corporate nurse acting as DON confirmed that the expectation was for licensed nursing staff to perform hand hygiene between glove changes in accordance with infection control standards and facility policy.