Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
Staff failed to maintain effective infection control practices, specifically regarding Enhanced Barrier Precautions (EBP) and hand hygiene. During tube feeding care for a resident who had pulled out their feeding tube, a licensed nurse did not wear a gown as required by EBP protocols. In another instance, two certified nurse aides transferred a resident using a mechanical lift and provided a shower without donning gowns for EBP. After using the Hoyer lift, staff did not disinfect the equipment before moving it into the hallway. Additionally, a certified nurse aide provided peri-care to a resident and changed their brief while wearing the same soiled gloves, then handled the bedpan and continued care without performing hand hygiene between glove changes. The aide later acknowledged that handwashing should have occurred after glove removal and before continuing care. The facility's policy required appropriate precautions for residents with multidrug-resistant organisms (MDROs) and adherence to EBP, but these protocols were not consistently followed during observed care activities.