Failure to Follow Hand Hygiene and Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Facility staff failed to follow established infection prevention and control policies, including hand hygiene and appropriate glove use, during wound care for one resident. The facility’s handwashing and glove-use policy, revised 1/2024, requires hand hygiene before and after direct resident contact, between contaminated and clean body sites, after contact with intact skin, blood or body fluids, contaminated equipment, and after removing gloves, as well as proper glove application and removal. During an observed wound dressing change for Resident 4, an LPN performed initial hand hygiene, then donned gloves from a box and removed the wound dressing. The LPN then removed the gloves, took additional gloves from the pocket of the scrub top, and continued wound cleansing and dressing steps, repeating this process of using pocketed gloves without performing hand hygiene between glove changes. The LPN later acknowledged that hand hygiene should have been completed between glove changes and that gloves should not have been taken from personal pockets but from a clean glove box. The facility’s MDRO PPE-Enhanced Barrier Precautions policy, revised 1/2024, requires gown and glove use for high-contact care activities, including wound care, for residents with wounds or MDROs, and specifies that everyone must clean their hands before entering and when leaving the room. Resident 4’s record showed diagnoses of ESBL resistance and a personal history of MRSA infection, and an EBP magnet was present on the room door frame. During another observed wound care episode for this resident, an LPN entered the room with a treatment cart, did not don a gown, and placed wound care supplies on an uncleaned bedside table without disinfecting the surface or using a protective barrier. Scissors already on the bedside table were used to cut xeroform gauze without prior disinfection. The LPN confirmed that the treatment cart should not have entered the room, that EBP (gown and gloves) should have been used for the dressing change, that the table should have been disinfected before placing supplies, and that the scissors should have been disinfected before use. The DON confirmed that the EBP signage process is the expectation for all staff providing high-contact care to residents on EBP, including those with EBP magnets on their door frames.
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