Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to follow its infection prevention and control policies during wound care for a resident on enhanced barrier precautions. Specifically, a Physician Assistant and an agency nurse did not don gowns and gloves before entering the resident's room, as required by the facility's Enhanced Barrier Precautions (EBP) policy. The nurse donned multiple layers of gloves at the wound care cart, used hand sanitizer, and entered the room without a gown. The Physician Assistant washed his hands and donned gloves at the bedside but also did not wear a gown. During the wound care procedure, the nurse removed and replaced dressings and bandages on both of the resident's feet and legs, but failed to change gloves or perform hand hygiene between steps, instead relying on removing outer layers of gloves. Hand hygiene was not performed between glove changes or between care of different wounds, contrary to facility policy. Interviews with staff revealed that the Physician Assistant was unaware the resident was still on enhanced barrier precautions, and the agency nurse misunderstood the facility's glove use policy, believing multiple layers of gloves were acceptable. The Unit Manager and Director of Nursing confirmed that the correct procedure was not followed, and that signage and supplies for EBP were present on the resident's door. The nurse involved had completed the facility's infection control and handwashing training prior to the incident.