Failure to Implement Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to implement adequate infection prevention and control practices for a resident requiring enhanced barrier precautions (EBP) due to the presence of an indwelling suprapubic catheter, an open stage three pressure ulcer, and a current urinary tract infection (UTI). The resident had multiple diagnoses, including neurogenic bladder, dementia, Parkinson's disease, and osteoporosis, and required substantial assistance with activities of daily living. The care plan directed staff to monitor the catheter and wound but did not include EBP instructions. During direct care, staff entered the resident's room without donning required personal protective equipment (PPE), specifically gowns and gloves, despite clear EBP signage and available supplies outside the room. Staff assisted the resident with transferring, catheter care, wound care, and personal hygiene without consistently using gowns, and at times failed to perform hand hygiene between glove changes. Observations included staff handling soiled items, performing dressing changes, and providing peri care without proper PPE or hand hygiene, even after exposure to urine and wound sites. Interviews with the involved nursing assistants and LPN confirmed awareness of the EBP requirements and acknowledged lapses in following protocol, attributing failures to forgetfulness or unexpected care needs. The director of nursing also confirmed that staff were expected to follow EBP signage and that sitting on the floor during care was not recommended due to infection control concerns. Facility policy and posted signage clearly outlined the need for gown and glove use during high-contact care activities for residents on EBP, which was not followed in this instance.