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Based on Observation, Record Review and Interview, facility staff failed to follow their policy and CDC (Centers for Disease Control) guidelines for performing appropriate hand hygiene when providing patient care in 1 (Patient #5) of 2 wound care observations observed for Pt. #5 on the medical surgical unit.

Findings Include:

Patient #5 was a 66 year old admitted on 06/03/2024 with an infected Sacral (area between lower back and tailbone) decubitus ulcer (pressure injury) and a concern for osteomyelitis (bone infection). Pt. #5 had a BMI (Body Mass Index) of 44.53 (morbidly obese).

Review of Facility Policy, effective date 12/01/2023 titled, "Hand Hygiene/Fingernails Procedure," revealed, "Purpose to set forth minimum requirements on performing hand hygiene, which are consistent with the World Health Organization and Centers for Disease Control and Prevention (CDC) guidelines.....Policy: Hand hygiene must be performed using alcohol-based hand rub...Hand hygiene must be performed in patient care setting: Before patient contact. Before clean/aseptic procedure. After patient contact; After contact with blood or body fluids and after glove removal. After contact with patient surroundings or environment (e.g. between contact with dirty and clean items)....When moving from a contaminated body site or activity to another body site during patient care."

Review of Facility Policy, revision date 02/20/2024 titled, "Moist saline gauze dressing application," revealed, "The procedure detailed here addresses cleaning and dressing a wound with moist saline gauze. Health Care workers must always follow the Centers for Disease Control and Prevention's standard precautions guidelines when providing wound care....Implementation...Gather necessary equipment and supplies. Perform hand hygiene....Raise the bed to waist level before providing care....perform hand hygiene.....open the package of supplies....perform hand hygiene....put on gloves remove the existing dressing....assess the wound.....clean the wound....remove and disgard your gloves. Perform hand hygiene. Put on a new pair of sterile or clean gloves.....assess the wound......moisten the gauze dressing...place the dressing....Cover the moist gauze with a dry dressing....discard used supplies....remove and disgard gloves....perform hand hygiene."

On 06/04/2024 from 11:15 AM through 11:35 AM observed Registered Nurse (RN) H perform wound care to a stage 4 pressure ulcer on the coccyx of Patient #5 who was admitted for treatment for an infected sacral pressure injury. Pt. #5's wound care was to be completed twice daily and as needed with acetic acid damp to dry gauze dressing changes to the large open sacral pressure injury. During the observation RN H was observed to don clean gloves, remove Pt. #5's old dressing, clean stool and wipe the perineum area, then touched the patient's hip, continue to clean up the stool, rolled the blue pad up. RN H then drew up the solution with a syringe, opened the package of kerlix gauze and proceeded to apply the solution to the rolled gauze. Then took a sterile q-tip and used the q-tip to pack the gauze into Pt. #5's open sacral wound, cut the remainder of the gauze that wasn't needed, covered the wound with a new dressing and taped the edges. RN H did not perform hand hygiene at anytime during the wound care performed on Pt. #5.

On 06/05/2024 at 10:19 AM in an interview with Wound Care RN F when told of the findings of the observation on 06/04/2024 with RN H, Wound Care RN F was asked if staff should be performing hand hygiene when providing wound care, F stated, "Yes they should be."