Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to follow established infection control guidelines from CMS and CDC, as well as its own policy, during the care of a resident with an indwelling catheter, wound infection, Multiple Sclerosis, and a Stage 4 pressure ulcer. The resident had physician's orders for Enhanced Barrier Precautions (EBPs), which require staff to wear gloves and gowns during high-contact care activities. Despite clear signage and policy, two nurse aides entered the resident's room wearing only gloves and proceeded to provide high-contact care, including rolling the resident, removing soiled dressings, providing incontinent care, and handling a mechanical lift sling, without donning gowns as required. Additionally, one of the nurse aides failed to remove gloves and perform hand hygiene after removing wound dressings and providing incontinent care, before continuing with other care tasks. Both aides only removed their gloves and used hand gel after several care activities had already been performed. These actions were confirmed by the Director of Nursing to be inconsistent with facility policy and infection control guidelines, specifically regarding the use of gowns and proper hand hygiene during care for residents on EBPs.