Failure to Implement Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
Certified Nursing Assistant (CNA) 5 failed to implement required infection control measures for two residents during direct care activities. Specifically, CNA 5 did not use enhanced barrier precautions (EBP), such as wearing a gown and gloves, while providing high-contact care to a resident with a gastrostomy tube, as ordered by the physician and outlined in the resident's care plan. Additionally, CNA 5 did not perform hand hygiene between caring for two different residents or after removing gloves, despite facility policy and training indicating this as a critical step to prevent infection transmission. Resident 13 had diagnoses including generalized muscle weakness and dementia, with severely impaired cognition and dependence on staff for personal hygiene and bed mobility. Resident 78, who also had severely impaired cognition and was dependent on staff for personal hygiene and dressing, had a gastrostomy tube and was under physician orders and a care plan requiring EBP. During observations, CNA 5 was seen assisting Resident 78 with activities of daily living and then immediately providing care to Resident 13 without changing gloves, donning a gown, or performing hand hygiene between residents. Interviews with CNA 5 and the Infection Preventionist Nurse confirmed that staff were aware of the requirements for hand hygiene and EBP, and that failure to follow these protocols could lead to the spread of infection. Review of facility policies further supported that EBP and hand hygiene were required during high-contact care and between resident interactions. The observed lapses in infection control practices placed the residents at risk for infection and illness.