F0880

E

Failure to Follow Hand Hygiene and PPE Protocols During Wound Care and Insulin Administration

El Paso, Texas Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain and implement an effective infection prevention and control program, specifically related to hand hygiene and PPE use during wound care and blood glucose monitoring with insulin administration. During wound care for a resident with a sacral pressure injury, an LVN donned a PPE gown without securing the back or neck ties, disposed of the resident’s soiled wound dressing, and continued to clean the wound without performing hand hygiene or changing gloves. The LVN then removed and discarded the gown because it was getting in the way and continued cleaning the wound without a gown. He began to open new dressings to apply to the wound and only performed hand hygiene and changed gloves after being stopped and questioned by the state surveyor. He completed the remainder of the wound care without wearing a PPE gown.

The resident receiving this wound care had a documented Stage 4 pressure injury to the sacrum, with orders for daily alginate calcium primary dressing and gauze island secondary dressing, and a care plan directing staff to administer treatments as ordered and monitor for changes in skin status. The LVN later stated he forgot to wash his hands and change gloves after disposing of the dirty dressing and cleaning the wound, and acknowledged he was expected to perform hand hygiene before applying the new dressing. He reported he did not typically provide wound care because the facility had a designated wound care nurse, and that he removed the gown because it was too small and not secured, noting that larger gowns previously provided had run out and that he was supposed to notify the nurse supervisor when PPE supplies were low. The DON stated staff were to don gown and gloves at minimum for wound care, that it was not appropriate to remove the gown during the procedure without reapplying it, and that staff were expected to perform hand hygiene before applying PPE, before beginning wound care, when changing gloves during wound care, and before applying the new dressing.

Additional deficiencies were observed in hand hygiene practices during glucose monitoring and insulin administration for four residents with diabetes and varying degrees of cognitive impairment. An RN performed blood glucose checks and insulin injections for multiple residents without sanitizing her hands between glucose measuring and filling the insulin syringe, and in some instances did not sanitize after administering insulin, disposing of sharps, and removing gloves before touching the medication cart and a resident’s door handle. She also proceeded from one resident to another without practicing hand hygiene between residents. In interviews, the RN acknowledged she should sanitize before and after every glove application, admitted she did not adhere to that standard, and attributed her lapses in part to not having hand sanitizer readily accessible on her cart. Other nursing staff, supervisors, the unit manager, ADON, and the DON described the expected procedure for glucose monitoring and insulin administration, consistently stating that there should be multiple (3–4) hand hygiene opportunities during the process, including before and after glove use and between residents, and that staff were responsible for following the facility’s hand hygiene and infection control policies. Facility policies on hand hygiene and infection prevention and control required staff to perform hand hygiene per established procedures and to use PPE according to facility guidelines when providing resident care.