Failure to Follow Hand Hygiene and Clean Field Practices During Wound Care
Penalty
Summary
The deficiency involves a failure to follow infection prevention and control practices during wound care for one of three sampled residents. The resident was admitted in February 2026 with a diagnosis of aftercare following joint replacement surgery and had moderate cognitive impairment per an MDS dated 2/16/26. During an observation on 2/26/26 at 10:37 a.m., the resident was lying supine in bed with steri-strips to the left thigh while a licensed nurse performed wound care. The nurse placed wound care supplies directly on the resident’s bed without establishing a separate clean and dirty area, contrary to the facility’s wound care policy that required use of a disposable cloth or paper towel to establish a clean field. During the same observation, the licensed nurse did not perform hand hygiene between glove changes at 10:37 a.m., 10:39 a.m., and 10:41 a.m. The nurse confirmed there was no separate clean and dirty section during the procedure, which increased the potential for the resident to get infections through cross contamination. The Infection Preventionist stated that the expectation was to perform hand hygiene before and after glove changes, sanitize non-dedicated equipment after each use, and maintain separate clean and dirty areas during wound care. The DON similarly stated that staff were expected to perform hand hygiene after each glove change, sanitize equipment after use, and maintain separate clean and dirty areas during wound care, consistent with facility policies on hand hygiene and wound care.
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