Failure to Follow Hand Hygiene Protocols for Resident on Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to follow appropriate infection control practices for a resident on enhanced barrier precautions (EBP), an intervention designed to reduce the transmission of multidrug-resistant organisms. During an observation, both the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) entered the resident's room without performing hand hygiene before entry, before touching the resident's linen, after assisting the resident, and before leaving the room. Interviews with both the DON and the LVN confirmed that staff are expected to perform hand hygiene before resident contact and between residents, especially when EBP is in place, and that failure to do so can lead to infection transmission. A review of the resident's care plan indicated the individual was at high risk for infection due to a medical history of previous infections, with interventions including hand hygiene during care to reduce infection risk. The facility's policy on hand hygiene, dated April 2023, required the use of alcohol-based hand rub before and after direct contact with residents and after contact with objects in the resident's immediate vicinity. These protocols were not followed during the observed care of the resident.