Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
Staff failed to follow infection prevention and control guidelines during care of residents, specifically in the application of enhanced barrier precautions (EBP) and hand hygiene protocols. For one resident with a tracheostomy, an LPN did not perform hand hygiene with alcohol-based hand sanitizer or soap and water before entering the room and donning a gown. After donning the gown, the LPN washed hands for only eight seconds, which is less than the recommended duration. The LPN also failed to disinfect the overbed table before using it as a workspace for sterile tracheostomy supplies and compromised aseptic technique by placing a non-sterile gloved thumb inside the sterile tracheostomy kit. These actions were confirmed by both the LPN and the Director of Nursing during interviews. Facility policy required EBP, including targeted gown and glove use during high-contact care activities such as tracheostomy care, and specified that hand hygiene should be performed before aseptic tasks. The policy also outlined that handwashing should last at least 15 seconds and that gloves do not replace hand hygiene. The tracheostomy care policy required aseptic technique and sterile gloves during procedures, as well as hand hygiene before and after glove use. These protocols were not followed during the observed tracheostomy care event. In a separate incident, a CNA was observed entering a resident's room wearing gloves, then exiting the room and assisting the resident to the dining room without removing or changing gloves. The CNA confirmed that the same gloves were worn throughout both activities. This practice did not align with infection control standards, which require glove removal and hand hygiene between resident care activities to prevent cross-contamination.