Failure to Follow Hand Hygiene and Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to wound care for one resident. The facility’s hand hygiene policy required use of alcohol-based hand rub or soap and water before handling clean or soiled dressings, before moving from a contaminated to a clean body site, after contact with a resident’s skin, after handling used dressings or contaminated equipment, and after removing gloves. The facility’s Enhanced Barrier Precautions (EBP) policy required gown and glove use for high-contact resident care activities, including wound care, for residents with wounds, and specified that EBPs remain in place for the duration of the resident’s stay or until wound resolution. The resident involved had a stage 4 sacral pressure ulcer, type 2 diabetes, and a UTI, with a physician’s order for sacral wound care including cleansing, application of gentian violet, collagen, and silver alginate, and covering with a dry dressing. During an observed wound care treatment, the treatment nurse and a CNA entered the resident’s room, which had an EBP sign posted instructing staff to wear gown and gloves for wound care, but neither staff member wore a gown. The treatment nurse removed the resident’s soiled dressing, removed her gloves, placed them on the bedside table, and donned clean gloves without performing hand hygiene between glove changes. She then cleansed the wound and applied gentian violet without changing gloves or performing hand hygiene after cleansing the wound. When the resident had a bowel movement, the nurse removed her gloves, placed them on the bed sheet, left the room without performing hand hygiene, returned with wipes and gloves, and again donned clean gloves without hand hygiene before cleaning the bowel movement. The nurse continued to alternate between cleaning bowel movements, changing briefs, and performing wound care while repeatedly removing used gloves, placing them on the bed sheet, and donning clean gloves without performing hand hygiene between glove changes or after glove removal. She exited and re-entered the room without hand hygiene after glove removal and did not discard used gloves in the trash as required. In interviews, the nurse acknowledged she did not bring hand sanitizer into the room, did not perform hand hygiene between glove changes, did not change gloves after cleansing the wound before applying gentian violet, and placed soiled gloves on the resident’s bed instead of discarding them. The CNA confirmed awareness of the EBP sign and the requirement to wear a gown and gloves for direct care but did not wear a gown. The DON/infection control nurse and another nurse assisting with infection control confirmed that hand hygiene between glove changes, proper glove disposal, and use of gown and gloves for wound care under EBP were required and were not followed in this instance.
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