Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during wound care for one resident. The resident had multiple diagnoses including chronic venous hypertension with ulcer, CHF, diabetes mellitus with foot ulcer, and atrial fibrillation, and had venous stasis ulcers to both lower extremities. Physician orders and hospital after-visit instructions directed that the bilateral lower extremity wounds be cleansed with normal saline or wound cleanser, followed by application of nonadherent dressings, ABD pads, and Kerlix. During an observed wound care procedure, the ADON wore a gown and gloves, removed the dressing from the resident’s left leg, discarded it, and then handled the wound cleanser bottle without removing gloves or performing hand hygiene. The ADON then sprayed the ulcer, grabbed gauze, and patted the wound with the same gloved hand. After this, the ADON removed her gloves and donned a new pair without performing hand hygiene in between. She then removed the dressing from the right leg and discarded it, again without performing hand hygiene as required. When questioned, the ADON stated that she did not need to perform hand hygiene until the entire dressing change was completed and questioned how she was supposed to perform hand hygiene between steps when there was no hand sanitizer in the room. In contrast, the RN infection preventionist stated that hand hygiene should be performed prior to entering a resident room, before applying gloves, between glove changes, and after contact with soiled items such as wound cleaning, and before touching clean wound supplies. The facility’s Hand Hygiene Policy required all staff to perform proper hand hygiene procedures to prevent the spread of infection, and additional facility guidance specified that glove use does not replace hand hygiene and that hand hygiene must be done before donning and immediately after removing gloves and after handling potentially contaminated items.
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