Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for a resident on enhanced barrier precautions due to a wound and an indwelling Foley catheter. On the observed date, multiple staff members, including a CNA and two LVNs, did not use the required personal protective equipment (PPE) such as gowns while providing high-contact care activities like wound care, dressing, and incontinence care. Specifically, staff entered the resident's room, which was marked for enhanced barrier precautions, and performed care activities wearing only gloves but no gowns, despite facility policy and physician orders requiring both gloves and gowns for such interactions. During wound care and incontinence care, one LVN failed to perform hand hygiene between glove changes when moving from dirty to clean tasks. The staff involved acknowledged during interviews that they were aware of the requirements for PPE and hand hygiene but cited reasons such as forgetting or lack of PPE supplies immediately available outside the resident's room. The absence of a PPE cart outside the room was noted as a contributing factor for non-compliance by one CNA. The resident involved was a female with a history of hypertension, end stage renal disease, and cerebral vascular accident, and was assessed as moderately cognitively impaired. Her care plan and physician orders specifically required enhanced barrier precautions, including the use of gloves and gowns for high-contact activities. Facility policy also emphasized the importance of hand hygiene and proper PPE use to prevent the transmission of infection.