F0880

D

Failure to Perform Required Hand Hygiene During Wound Care Under Enhanced Barrier Precautions

Fishers, Indiana Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its own infection control policies and procedures for hand hygiene during wound care for one resident under Enhanced Barrier Precautions. During an observed wound care session for a resident with a right lower extremity (RLE) wound and a sacral wound, an RN and the Wound Care Nurse repeatedly removed and changed gloves without performing hand hygiene or handwashing as required by facility policy. After removing the dressing from the RLE wound, both nurses discarded their gloves and donned new ones without any observed hand hygiene. Following completion of treatment to the RLE wound, they again removed and discarded gloves, then applied new gloves without hand hygiene before repositioning the resident for care of the sacral wound.

When the resident was repositioned, he was found to have an incontinent bowel movement, and both nurses removed and discarded their gloves, then donned new gloves to clean the resident and continue wound care, again without any observed hand hygiene or handwashing. The RN then provided sacral wound care, removed and discarded gloves, and applied new gloves without hand hygiene, and both nurses assisted the resident into a position of comfort and cleaned the area, removing and discarding gloves at the end without performing hand hygiene. In subsequent interviews, both the RN and the Wound Care Nurse acknowledged that hand hygiene or handwashing should have occurred between wounds and after cleaning the bowel movement. Review of the facility’s wound care procedure showed multiple explicit requirements to wash hands or perform hand hygiene before and after glove use and between steps of the wound care process, which were not followed during this observed care.