Failure to Adhere to Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in adherence to Enhanced Barrier Precautions (EBP) and hand hygiene protocols. In one instance, an LPN and a nursing student were observed providing high-contact care to a resident with a pressure ulcer, who was under EBP, by pulling the resident up in bed while wearing only gloves and not donning the required gown. This action was inconsistent with both the facility's EBP policy and the CDC-based signage posted on the resident's door, which specified that both gown and gloves must be worn during high-contact care activities for residents with wounds. Interviews with staff revealed inconsistent understanding and application of EBP requirements, with some staff believing gowns were only necessary for wound care and not for other direct care activities such as repositioning a resident in bed. Another deficiency was observed during medication administration. An LPN dropped a pill onto the medication cart, picked it up with an ungloved hand, and placed it into a medication cup with other pills for a resident, rather than discarding the pill as required by policy. Shortly after, the same LPN donned gloves to administer insulin without performing hand hygiene beforehand, contrary to the facility's hand hygiene and medication administration policies. Interviews with the LPN and other staff confirmed a lack of adherence to proper hand hygiene and medication handling protocols, with some staff unaware that dropped pills should be discarded and that hand hygiene is required before donning gloves. The residents involved included one with a stage three pressure ulcer and multiple comorbidities, who had physician orders and a care plan specifying the use of EBP during high-contact care, and another resident with dementia, epilepsy, and diabetes who required medication administration. The observed failures to follow established infection control policies and procedures occurred despite the presence of clear facility policies, posted signage, and staff education on EBP and hand hygiene. These lapses were confirmed through direct observation, record review, and staff interviews.