Failure to Follow Infection Control and Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed during wound care and feeding tube care for two residents. In one instance, a CNA assisted with wound care for a resident with multiple Stage IV pressure ulcers and a history of frostbite, gangrene, and vascular disease. The CNA handled trash, then donned gloves without performing hand hygiene, entered the resident's room, and assisted with wound care. The CNA also changed gloves without using hand sanitizer or washing hands, citing a non-functioning alcohol gel pump as the reason. Both the DON and Administrator confirmed that hand hygiene should have been performed before gloving and in between glove changes, especially after handling trash and before assisting with wound care. In another instance, an LPN failed to follow Enhanced Barrier Precautions (EBP) while flushing a feeding tube for a resident with severe cognitive impairment and a gastrostomy tube. The LPN did not wear a gown during the procedure, despite EBP signage indicating the requirement for gown and gloves during device care. Interviews with staff and review of facility policies confirmed that EBP should be used for residents with indwelling medical devices, and that PPE was available in resident rooms. Additionally, the facility's wound care policy did not address hand hygiene during wound care, and the infection prevention policy referenced CDC guidance but did not specify procedures for these situations.