Failure to Follow PPE and Hand Hygiene Protocols During Resident Care and Laundry Handling
Penalty
Summary
A deficiency occurred when a registered nurse failed to wear the required personal protective equipment (PPE), specifically a gown, while performing gastrostomy (G-tube) care for a resident on Enhanced Barrier Precautions (EBP). The nurse entered the resident's room, which had a visible EBP sign, and conducted a G-tube placement check using gloves but did not don a gown. The nurse handled the resident's G-tube and associated equipment, including removing and connecting a piston syringe, without the additional barrier protection mandated by facility policy and the posted EBP instructions. Both the infection preventionist and the nurse acknowledged that EBP requires the use of gown and gloves for device care, such as G-tube management, to prevent the transfer of microbes to residents with medical devices or open wounds. Another deficiency was observed in the facility's laundry operations. The housekeeping supervisor was seen pushing a soiled linen cart with bare hands into the laundry area and then handling clean laundry items without performing hand hygiene. The supervisor also touched multiple surfaces after handling soiled items and noted that soiled linen was present in the laundry chute without being contained in a bag, contrary to facility policy. The supervisor admitted that hand hygiene should have been performed after handling the soiled cart and before touching clean items, and that soiled linen should always be bagged to prevent contamination. Facility policies require the use of PPE during high-contact resident care activities, such as feeding tube care, and mandate hand hygiene when moving from dirty to clean tasks. The policies also specify that contaminated linen must be placed in biohazard bags and that staff must follow recognized hand hygiene procedures to prevent the spread of infection. These requirements were not followed during the observed incidents, resulting in deficiencies in the facility's infection prevention and control program.