Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
Facility staff failed to follow infection prevention and control protocols for residents on Enhanced Barrier Precautions (EBP) and during incontinence care. Certified Nursing Assistants (CNAs) were observed not donning required personal protective equipment (PPE), such as gowns and gloves, when providing care to residents with wounds or those on EBP. In multiple instances, staff did not change gloves or perform hand hygiene when moving from contaminated to clean areas during incontinence care. For example, one CNA provided care to a resident with urine and stool in the incontinence brief without changing gloves or performing hand hygiene, and did not wear a gown as required by EBP protocols. Similar failures were observed with other residents, including not changing gloves or performing hand hygiene after cleaning soiled areas and before handling clean items or applying dressings. Additionally, a CNA was observed providing care to a resident with pressure wounds without wearing a gown or gloves initially, and only applied gloves after handling the resident's oxygen tubing. The facility's policies require the use of gowns and gloves for high-contact care activities for residents with wounds or indwelling devices, and mandate hand hygiene and glove changes between dirty and clean tasks. Interviews with staff, including the Director of Nursing and Infection Prevention Nurse, confirmed the expectation for proper PPE use and hand hygiene, but these practices were not consistently followed during the observed care events.