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Based on observation, interview, and record review the the facility failed to implement the nursing plan of care as per the facility Guidelines for Hand Hygiene and facility Nursing Standards/Procedures for performing wound care/dressing change. This affected 1 of 3 sampled patients (#3).

The findings Include:

During an observation of patient #3's sacral pressure sore dressing change performed on 02/17/10 at 3:40 PM by a Registered Nurse (RN), the nurse did not perform the dressing change in accordance with the facility's Guidelines for Hand Hygiene and standard procedures for wound care/dressing change. The nurse gathered the supplies (several packages of sterile 4 x 4 gauze, 1 bottle of prescribed Dakin solution and 1 roll of paper tape) and placed all of the supplies on the patient's bed side table. The nurse applied gloves, removed the soiled dressing, exposed the wound then washed her hands. After washing her hands from her wrist down to her fingers she used the back of her hands to turn the faucet off. A second RN assisted the nurse by opening several packets of sterile gauze and resting the opened packages on the bedside table. The RN performing the dressing change placed clean gloves on and poured the Dakin solution unto the gauze. The solution soaked through the gauze unto the bedside table, contaminating the sterile gauze. The RN then applied several pieces of the soaked, contaminated gauze to the wound and covered the wound with more sterile gauze. The RN did not clean the inside of the wound or around the outer areas of the wound. The area around the wound was observed to be dry and soiled from the dressing and tape that was removed. The RN then used a marker to initial and date the dressing before removing the soiled gloves. After discarding the soiled gloves, the nurse washed her hands. The assisting RN wiped the patient's soaked bedside table with a dry paper towel, placed the excess supplies, including the Dakin solution, in a box and stored the box on the window ledge in the patient's room.

During an interview with the RN who performed the dressing change after the observation, the RN was asked whether she had cleaned the wound. The RN stated, "No." The RN agreed that she had not not changed her soiled gloves immediately after performing the dressing change. The RN confirmed that she uses the back of her hands or elbows to close the faucet.

During an interview with the nurse manager after the observation, the manager stated that Dakin solution is like "bleach." It is a cleansing agent and and therefore it cleans the wound. The manager stated that the Dakin solution is usually kept in the patient's closet and that there was no need to clean the patient's bedside table.

During an interview with the wound care nurse conducted on 02/17/10 at 4:55 PM, the nurse confirmed that the nurse should have cleaned the wound before applying the new dressing.

During an interview conducted with the Administrative Director Nursing Support Services on 02/17/10 at approximately 4:55PM, the director stated that the facility does not have a specific policy for dressing changes. The director stated that wound care/dressing guidelines outlined in the book: "Critical Nursing Skills &Technique-Mosby 7th Edition," is the guideline that nursing staff is expected to follow when performing dressing changes.
A review of the Critical Nursing Skills & Technique-Mosby 7th Edition wound care/dressing guidelines revealed that the wound should be cleaned from the least contaminated area to the most contaminated area before the dressing is applied.

The facility's Guidelines for Hand Hygiene policy specifies at # 4: "Use paper towel to turn off the faucet."