Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols during high-contact resident care activities for three residents. In one instance, a female resident with a urinary tract infection and neuromuscular bladder dysfunction was observed with an indwelling catheter bag on the floor, which had not been emptied as required. A CNA emptied the bag without wearing a gown, despite EBP signage indicating the need for both gloves and a gown during such care. The CNA was also unaware of when the bag was last emptied. In another case, a male resident with an infection related to an indwelling urethral catheter was cared for by an LPN who touched the resident's linen and catheter tubing without wearing a gown, contrary to EBP requirements. The DON confirmed that staff are expected to wear gowns and gloves for high-touch care activities involving residents on EBP, and that catheter bags should not be placed on the floor. Additionally, during incontinence and wound care for another resident, a wound care nurse practitioner and a registered nurse failed to perform appropriate hand hygiene. After removing stool from the resident's buttocks with a wipe, the RN did not change gloves before assisting with wound measurement, resulting in contact with clean areas of the resident while still wearing soiled gloves. The DON stated that gloves should be removed and hands washed after incontinence care and before touching clean areas, in accordance with the facility's hand hygiene policy.