Failure to Consistently Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to consistently implement enhanced barrier precautions (EBP) and appropriate hand hygiene practices as required by CDC guidelines and facility policy. In one instance, a cognitively intact resident with a history of vancomycin-resistant enterococci (VRE) infection in urine was care planned for EBP, which required staff to wear gloves and gowns during high-contact care activities such as transferring and toileting. Despite clear signage and care plan instructions, staff assisted the resident with transferring from bed to wheelchair and toileting without donning the required gowns. Staff interviews revealed a lack of awareness and adherence to EBP protocols, with one nursing assistant admitting to forgetting to wear PPE and another unsure of the reason for the precautions. Additionally, the facility failed to ensure proper hand hygiene during personal care for another resident with severe cognitive impairment and total dependence on staff for activities of daily living. During morning care, a nursing assistant removed soiled gloves after cleaning the resident but did not perform hand hygiene before donning new gloves or after completing care. This lapse was observed despite the facility's policy and staff interviews confirming the expectation to use hand sanitizer or wash hands after glove removal, especially after contact with body fluids or excretions. The observations and staff interviews demonstrated that the facility did not consistently follow its own policies or CDC recommendations regarding the use of PPE and hand hygiene during high-risk resident care activities. These failures were directly observed during care provision and confirmed by staff statements, indicating a breakdown in infection prevention and control practices for residents at risk of infection or colonization with multidrug-resistant organisms.