Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care and Housekeeping
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in following Enhanced Barrier Precautions (EBP) and proper hand hygiene during resident care. During wound care for two residents with significant wounds, staff members, including a CNA, RN, Nurse Manager, ADON, and LPN, did not don gowns as required for high-contact care activities. In one instance, a Nurse Manager performed wound care on a resident's stage 3 pressure ulcer without wearing a gown, although she did perform hand hygiene and changed gloves between steps. In another case, both the ADON and LPN failed to wear gowns during wound care for a resident and did not change gloves after removing soiled packing from the wound, contrary to CDC guidelines. Staff interviews revealed a lack of awareness and training regarding EBP requirements, with some staff believing gowns were only necessary for wounds with resistant organisms or visible drainage. Housekeeping staff also failed to adhere to infection control protocols. During cleaning of a triple occupancy resident room, a housekeeper did not change gloves after cleaning the bathroom (a dirty area) before moving to clean areas within the same room. Additionally, high-touch surfaces such as door knobs, light switches, and call lights were not cleaned or sanitized during the observed cleaning process. The Maintenance Director confirmed that housekeeping staff were expected to change gloves between rooms and clean high-touch surfaces at least twice per week, but was unaware that gloves should be changed during the cleaning of a single room. These deficiencies were identified through direct observation, staff interviews, and record review. The lapses in following EBP, hand hygiene, and environmental cleaning protocols were not limited to isolated incidents but reflected a broader lack of consistent training and adherence to infection control standards among both nursing and housekeeping staff.