Improper Glove Use and Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program when a nurse did not follow proper hand hygiene and glove practices during wound care for one resident. The resident was an older male with acute respiratory failure, ventilator dependence, quadriplegia, and pressure ulcers of the sacrum and left buttock. His care plan included weekly wound assessments and specified Enhanced Barrier Precautions, including donning gloves and gown for wound care and other high-contact activities. Physician orders directed specific daily and PRN wound treatments for the stage 4 pressure wound on the left buttock and the sacral wound. During a wound care observation, the LVN donned a gown with thumb holes over a first pair of gloves, then applied a second pair of gloves over the first pair. She removed the resident’s sacral and left buttock dressings, then removed only the top glove from her right hand and replaced it with a new glove, leaving the original base gloves on both hands and not performing hand hygiene. She used the right hand to clean the sacral wound, again removed only the right top glove with her left gloved hand, donned a new right glove, applied treatment and dressing to the sacrum, and then removed the right glove. She continued to use the unchanged left base glove to remove soiled right-hand gloves and did not change both gloves between wound sites. She then used the unchanged base gloves to clean the left buttock wound before finally removing both gloves, using alcohol-based hand sanitizer, and donning new gloves. The LVN later stated she had not received wound care competency check-off upon hire and relied on prior experience from another state. She acknowledged awareness that the resident had a history of MDRO and required contact precautions. She reported that she double gloved based on prior home care practice and concern about glove breakage and contamination, and believed the left glove remained clean because she did not use that hand directly in the wound. She also stated she used hand hygiene between some glove changes due to potential contamination. Facility policy on infection control specified that hand hygiene must be performed after removing gloves and that gloves are not a substitute for hand hygiene, and identified failure to change gloves between resident contacts as an infection control hazard.
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