Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to implement proper infection prevention and control practices during wound care and incontinent care for two residents. During wound care for a resident with a stage IV pressure injury, both the LPN and CNA assisting did not wear gowns as required by the facility's Enhanced Barrier Precautions (EBP) policy. Both staff members acknowledged forgetting to don gowns, despite having received prior training on EBP. The facility's policy specifies that gowns and gloves must be used during high-contact care activities to prevent the transmission of multidrug-resistant organisms. In a separate incident, a CNA providing incontinent care to another resident did not perform hand hygiene between glove changes and used soiled gloves to handle clean supplies. The CNA also failed to don a new gown or wash hands before starting care after removing a previously used gown in the hallway. Both the Infection Prevention Nurse and the Director of Nursing confirmed that the staff did not follow required infection control protocols, including proper gown use and hand hygiene, placing residents at risk for infection.