Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for one resident and two staff members. Specifically, two CNAs did not follow enhanced barrier precautions (EBP) and proper hand hygiene protocols while providing incontinent care to a resident who required EBP due to a feeding tube. Both CNAs failed to wear gowns as indicated by the EBP signage on the resident's door. During care, one CNA continued to wear soiled gloves while turning the resident and handling clean items, while the other CNA changed gloves without performing hand hygiene. Additionally, one CNA left the resident's room with soiled gloves on, further breaching infection control protocols. The resident involved was a male with a history of cerebral infarction, dependent on staff for all activities of daily living, incontinent of bowel and bladder, and required a feeding tube. Both CNAs had documented training on infection control measures, including EBP and hand hygiene, prior to the incident. Interviews with the CNAs and facility leadership confirmed awareness of the required protocols and acknowledged the lapses in following established infection control policies during the observed care.