Failure to Implement Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, specifically regarding the use of Enhanced Barrier Precautions (EBP) and hand hygiene during incontinence care for residents with a history of colonization with Vancomycin-resistant Enterococci (VRE). Observations revealed that staff did not consistently wear required personal protective equipment (PPE), such as gowns and gloves, during high-contact care activities for residents on EBP. In two separate instances, staff members provided incontinence care and repositioned residents without donning gowns, despite clear signage and available PPE at the residents' doors. Interviews with the staff confirmed a lack of understanding or awareness of the EBP requirements. Additionally, the facility did not ensure proper hand hygiene practices during and after resident care. One staff member was observed changing a resident's soiled brief and performing perineal care, then proceeding to handle clean items, linens, and equipment without changing gloves or performing hand hygiene. The same staff member also failed to perform hand hygiene after removing gloves and before and after retrieving and using a mechanical lift for the resident. These actions were in direct violation of the facility's hand hygiene policy, which requires handwashing or use of hand sanitizer before and after resident contact, after glove removal, and after contact with bodily fluids. The residents involved had documented histories of VRE colonization and were under physician orders and care plans specifying the need for EBP. Facility policies and posted instructions clearly outlined the requirements for PPE use and hand hygiene, yet these were not followed during observed care activities. Interviews with the Director of Nursing and staff confirmed the expectations for PPE and hand hygiene, as well as the failure to adhere to these protocols during the incidents.