Improper Hand Hygiene and Wound Care Technique During Pressure Ulcer Treatment
Penalty
Summary
The deficiency involves failure to provide appropriate pressure ulcer care and to follow infection control practices during wound treatment for one resident. The resident had a documented stage 2 pressure injury on the left buttock, with medical orders to cleanse the wound with wound cleanser, apply a thin layer of Santyl ointment, and cover with a Mepilex padded dressing. The facility’s Clean Dressing Change policy required a no-touch technique for ointment application, use of applicators such as tongue blades, cleansing the wound as ordered, patting dry with gauze, and performing hand hygiene before donning clean gloves to apply topical treatments and dressings. During an observed wound care episode, the RN first donned gloves to wipe the resident after toileting and then removed the gloves, but did not perform hand hygiene before donning new gloves to remove the existing dressing, which contained yellow drainage. After removing those gloves, the RN again failed to cleanse hands before donning clean gloves to spray the wound with cleanser and wiped the wound with a washcloth instead of clean or sterile gauze. While wearing the same gloves, the RN used a gloved finger to remove Santyl from its container and apply it directly to the wound bed, contrary to the facility’s no-touch policy. The RN then removed the gloves, again without hand hygiene, donned new gloves, applied and dated a Mepilex dressing, and removed the gloves without cleansing hands between glove changes. The DON later confirmed that staff were expected to perform hand hygiene between glove changes and to use appropriate materials and applicators for cleansing and ointment application.
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