Failure to Follow Infection Control Protocols and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to adhere to proper infection prevention and control practices for two residents who were on Enhanced Barrier Precautions (EBP). In one instance, a certified nursing assistant (CNA) entered a resident's room, donned a gown but did not wear gloves while applying lotion, repositioning the resident, and handling both clean and dirty linens. The CNA did not perform hand hygiene during care and only sanitized hands after leaving the room. The required hand sanitizer was not accessible in the resident's room, and the CNA was unsure about EBP training, although she acknowledged prior handwashing in-service. For another resident with diabetes on EBP, a licensed practical nurse (LPN) did not perform hand hygiene before donning PPE and entering the room to perform a fingerstick blood sugar check. After the procedure, the LPN washed hands but then handled the used glucometer, placing it on the medication cart before cleaning it. The LPN cleaned the glucometer with an alcohol prep pad, despite the manufacturer's instructions specifying the use of a germicidal cleaning wipe, not alcohol. Staff interviews revealed inconsistent knowledge and practices regarding EBP and proper disinfection of shared equipment. Facility policy reviews confirmed that EBP requires gloves and gowns for high-contact care and that hand hygiene supplies should be present in each room. The facility's own procedures and the glucometer manufacturer's guidelines were not followed, as staff used unapproved cleaning agents and did not consistently perform hand hygiene or use PPE as required. Staff interviews indicated gaps in training and understanding of EBP protocols and infection control standards.