Failure to Follow Hand Hygiene Protocol During Wound Care
Penalty
Summary
The deficiency involves a failure to follow the facility’s Hand Hygiene policy during wound care for Resident #57, who had an unstageable pressure ulcer to the sacrum with orders to cleanse the wound with normal saline, pat dry, apply alginate with silver, and cover with a dry dressing daily and as needed. The facility’s policy required hand hygiene before donning and after removing gloves, before and after handling clean or soiled dressings, and before moving from a contaminated body site or procedure to a clean one, and specified that glove use does not replace hand hygiene. During an observed wound care procedure, the Wound Care Nurse initially followed protocol by cleansing the overbed table, placing a barrier and supplies, doffing gloves, sanitizing hands, and donning clean gloves before cleaning the sacral wound bed. After cleaning the wound bed, the Wound Care Nurse doffed her gloves, sanitized her hands, donned clean gloves, and cleaned the outer wound area with normal saline–soaked gauze and patted the wound dry. However, she then proceeded to cut the alginate with silver dressing and place it on the wound bed without doffing her gloves, sanitizing her hands, and donning clean gloves between the dirty procedure (cleansing the wound and surrounding area) and the clean procedure (cutting and applying the dressing), contrary to the facility’s Hand Hygiene policy. Subsequent interviews with the Infection Preventionist, the Wound Care Nurse, the DON, and the Administrator confirmed that the nurse did not perform the required glove change and hand hygiene at that point in the procedure and that the expectation was for the policy to be followed during wound care.
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