Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when a wound care nurse failed to perform hand hygiene between glove changes during wound-related care. During an observation, the wound care nurse cleansed a resident’s perineal wound area, removed soiled gloves, then immediately donned a clean pair of gloves and applied cream to the perineal area without performing handwashing or using an alcohol-based hand rub. In a subsequent interview, the wound care nurse acknowledged not performing hand hygiene after removing the soiled gloves and before putting on clean gloves to continue the wound care. The resident involved had been admitted with multiple diagnoses, including cerebral infarction (stroke), type II diabetes mellitus, pneumonia, tracheostomy, gastrostomy, and adjustment disorder with depression. A recent MDS assessment documented a BIMS score of 12 out of 15, indicating moderate cognitive impairment. The DON stated that staff are expected to follow facility policy and perform hand hygiene when providing care and noted the facility’s hand hygiene policy states that hand hygiene is the single most important means of preventing the spread of infections and that the use of gloves does not replace handwashing.
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