Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to follow enhanced barrier precautions (EBP) and proper hand hygiene protocols for two residents. For one resident with multiple diagnoses including dementia, epilepsy, unspecified immunodeficiency, dysphagia, and a gastric tube, staff did not wear a gown while providing care, despite physician orders and facility policy requiring EBP for residents with medical devices. The Certified Nursing Assistant (CNA) involved acknowledged not wearing the required gown, and both the Director of Nursing and Infection Preventionist Nurse confirmed that gowns and gloves are necessary under EBP to prevent the spread of multidrug-resistant organisms. In a separate incident, another resident who was dependent on staff for all activities did not receive care in accordance with hand hygiene protocols. The CNA failed to perform hand hygiene before and after feeding the resident and after leaving and re-entering the room, contrary to facility policy. The CNA admitted forgetting to perform hand hygiene, and the Infection Preventionist Nurse confirmed the requirement to wash or sanitize hands before and after resident contact to prevent infection transmission.