Failure to Perform Hand Hygiene and Glove Changes During Wound Care
Penalty
Summary
The deficiency involves a failure to follow infection prevention and control practices, specifically hand hygiene and glove changes, during wound care for one resident. The resident had intact cognition and medical diagnoses including DM, anemia, CKD, and arthritis, and was admitted with an unstageable pressure ulcer on the left heel. The care plan and TAR directed daily dressing changes to the left heel using dry gauze, with saline to loosen the dressing if needed. During an observed dressing change, an RN performed initial hand hygiene, donned a gown and gloves, and set up a barrier and supplies on the tray table. The RN used scissors to cut off the old cling wrap dressing, placed the scissors on the tray table, and then, without performing hand hygiene or changing gloves, opened the NS, moistened gauze, and removed the stuck dressing from the wound. The RN continued the procedure using the same pair of gloves, including moistening additional gauze with NS to wash and dry the wound, replacing the NS lid and discarding it, and then opening a new nonstick pad and applying it to the wound, followed by wrapping the heel with cling. The RN then used the same uncleaned scissors to cut tape and secure the dressing before finally cleaning the scissors with a wipe at the end of the procedure. Hand hygiene and glove changes were not performed between removal of the soiled dressing, cleansing of the wound, and application of the new dressing, contrary to the facility’s own competency-based procedure for dressing changes, which required removal of gloves and hand hygiene after removing the soiled dressing, and again after cleaning the wound, before applying the new dressing. Interviews with facility leadership confirmed that staff were expected to follow these hand hygiene and glove-change steps and to clean scissors before reuse, and the RN had a documented competency for dressing change on file.
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