Failure to Perform Hand Hygiene Between Glove Changes During Wound and Personal Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during personal care, wound care, and catheter-related care for one resident. The resident had intact cognition, was dependent for toileting hygiene, required substantial/maximal assistance with rolling, used an indwelling catheter, and was always incontinent of bowel. Diagnoses included obstructive uropathy, and the resident had a Stage IV sacrococcygeal pressure ulcer requiring daily wound treatments, as well as deep tissue pressure injuries and a moisture-related rash under both breasts and in the peri area. Physician orders directed daily cleansing and dressing of the coccyx wound with Vashe solution, calcium alginate, Triad paste, and foam dressing; application of antifungal cream to the underside of both breasts and peri-area; Triad paste to left glute/thigh wounds; and skin prep and dressing changes to the nephrostomy tube site. During an observed care episode, an RN placed wound care supplies on a barrier pad on the resident’s bed and repeatedly changed gloves between multiple care tasks without performing hand hygiene in between glove changes. The RN donned gloves, handled supplies, then changed gloves without hand hygiene before cleaning bowel from the resident’s buttocks. After removing those gloves, the RN again donned clean gloves without hand hygiene to cleanse and dress the coccyx pressure ulcer. The RN then removed gloves and, without hand hygiene, donned new gloves to apply Triad cream to the back of the resident’s right thigh, followed by additional glove removal and re-donning without hand hygiene to apply antifungal cream under the right breast and to the groin area. Finally, the RN removed gloves and donned another clean pair without hand hygiene to apply skin prep and dress the nephrostomy tube site. The facility’s hand hygiene policy stated that glove use does not replace hand hygiene and that staff must perform hand hygiene prior to donning and immediately after removing gloves.
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