Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to follow evidence-based practices (EBP) for infection prevention and control during the care of a resident on enhanced barrier precautions. A certified nursing assistant (CNA) provided care to a resident with a PEG tube, who was on EBP, without donning a gown as required by facility policy. The CNA assisted the resident with toileting, changing clothing, and stripping bedding without wearing a gown, despite EBP signage and the availability of gowns and gloves at the room entrance. The CNA later acknowledged not following the EBP process, and the Director of Nursing confirmed that residents with PEG tubes require both gown and gloves for care activities under EBP. Additionally, the facility did not ensure proper handling of dirty linen and hand hygiene between resident care activities. A CNA was observed transporting unbagged soiled clothing through the hallway while wearing gloves, contrary to facility policy, and did not wash or sanitize hands between setting up meal trays for different residents. The CNA admitted to not knowing the hand hygiene policy and was observed performing multiple tasks for residents without appropriate hand hygiene. The administrator later clarified that dirty linen should be bagged, gloves should not be worn in the hallway, and hand hygiene is required between residents.