Failure to Follow Hand Hygiene and Infection Control Practices During IV Therapy and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its Infection Prevention and Control Program and Hand Hygiene policy during IV therapy and wound care. Facility policies required staff to perform hand hygiene after contact with non-intact skin, before dressing care or touching wounds, after handling used dressings, after touching equipment near a resident, and to wash hands thoroughly prior to flushing a PICC line. During a continuous observation of medication administration for Resident #28, Nurse #3 donned gloves, prepared medications at the medication cart, and then entered the resident’s room without removing gloves or performing hand hygiene. While still wearing the same gloves used to handle the medication cart and equipment, Nurse #3 hung and primed IV antibiotic tubing, manipulated the IV pump, removed the disinfecting cap from the PICC line, wiped the hub, flushed the PICC line, and connected the IV antibiotic tubing before finally removing gloves and performing hand hygiene after the IV was started. A second component of the deficiency occurred during wound care for Resident #2, who had a stage 4 sacral pressure ulcer with slough and a stage 3 left buttock pressure ulcer. The Wound Treatment Nurse performed initial hand hygiene and donned clean gloves, then cleansed the stage 4 sacral ulcer with wound cleanser and gauze, followed by cleansing the stage 3 left buttock ulcer without changing gloves or performing hand hygiene between the two wounds. The nurse then prepared and applied new wound dressings to both wounds while still wearing the same soiled gloves used for cleansing, and only removed the gloves and performed hand hygiene after all dressings were in place and the treatment was completed. A third observation involved wound care for Resident #22’s left buttock pressure ulcer. The Wound Nurse performed hand hygiene, donned a gown and clean gloves, and removed the old dressing. Without removing gloves or performing hand hygiene after handling the soiled dressing, the nurse proceeded to clean the wound with gauze soaked in wound cleanser and then opened new dressings while still wearing the same gloves. Only after opening the new dressings did the nurse remove gloves and perform hand hygiene, then donned new gloves to place calcium alginate in the wound bed, apply zinc oxide to the wound edges and surrounding area, and cover the wound with a dry dressing. These observed practices did not follow the facility’s infection control and hand hygiene policies requiring glove changes and hand hygiene at key points during wound care and invasive line management.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.