Failure to Follow Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to follow its own infection prevention and control policies and procedures regarding hand hygiene and Enhanced Barrier Precautions (EBP) for a resident with significant medical needs, including a gastrostomy tube and tracheostomy. During an observation, two sitters providing care to the resident were seen wearing gowns but not gloves while repositioning the resident and handling the tracheostomy tubing. The sitters were unable to explain the importance of wearing gloves or performing hand hygiene before care, and only donned gloves after being prompted, without performing hand hygiene beforehand. Further, the sitters admitted they did not perform hand hygiene before entering the resident's room, despite signage indicating that hand hygiene and the use of gowns and gloves were required for anyone entering. The sitters also demonstrated a lack of understanding of EBP and its significance in preventing the spread of multidrug-resistant organisms (MDROs), especially for residents with devices such as feeding tubes and tracheostomies. The Director of Nursing confirmed that staff are expected to perform hand hygiene before entering rooms, before and after care, and before donning PPE, and acknowledged the importance of glove use for residents on EBP. Review of facility policies confirmed these requirements, including that hand hygiene must be performed prior to donning gloves and immediately after removing them, and that EBP training is required for staff. The observed failures had the potential to transmit and spread infection within the facility.