Failure to Follow Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow infection prevention and control protocols, specifically regarding hand hygiene and the use of enhanced barrier precautions (EBP) for residents with indwelling medical devices or wounds. In multiple observed instances, certified nursing assistants (CNAs) and licensed nursing staff provided care to residents on EBP without wearing required gowns. During perineal care and wound care, staff did not change gloves between tasks, did not perform hand hygiene after removing gloves, and touched various surfaces and equipment with contaminated hands or gloves. For example, after providing perineal care to a resident with a urinary catheter, a CNA did not remove soiled gloves or perform hand hygiene before handling clean linens and touching the door. Similarly, a nurse performed wound care without changing gloves between tasks and failed to perform hand hygiene before leaving the room and handling clean supplies. Additional observations included staff performing blood sugar testing and other care for residents on EBP without wearing gowns, failing to perform hand hygiene after glove removal, and contaminating shared equipment such as medication carts and laptops. Facility policy required the use of gowns and gloves for care involving wounds or indwelling devices and emphasized hand hygiene as the primary method to prevent infection transmission. Despite this, staff did not consistently adhere to these protocols, as confirmed by interviews with the Director of Nursing and other staff.