Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
Staff failed to adhere to the facility's Enhanced Barrier Precautions (EBP) and hand hygiene protocols for two residents with gastrostomy tubes. For one resident with a history of cerebral infarct, right-sided hemiplegia, hemiparesis, dysphagia, and post-gastrostomy, observations showed that an LPN entered the resident's room multiple times to provide tube feeding care without donning the required gown and gloves, despite clear signage and physician orders indicating EBP. The LPN acknowledged not following the EBP protocol during an interview, and the facility's Infection Preventionist was made aware of the lapse. For another resident with a feeding tube who received the majority of her nutrition via enteral feeding, staff were observed not following proper PPE and hand hygiene procedures. An RN disconnected the feeding tube without wearing the required gown and gloves. On a separate occasion, an LPN donned a gown and gloves, but after removing her gloves to adjust her eyeglasses and rub her eye, she put on new gloves without performing hand hygiene in between. The LPN acknowledged that hand hygiene should have occurred between glove changes. These actions were not in accordance with the facility's EBP policy and procedures.