Failure to Follow Infection Control and Enhanced Barrier Precaution Protocols
Penalty
Summary
Facility staff failed to follow established infection prevention and control practices for multiple residents requiring enhanced barrier precautions and specialized care. In one instance, a registered nurse administered insulin to a resident with Type 2 Diabetes Mellitus and, after removing gloves, did not perform hand hygiene before leaving the room and documenting in the electronic health record. The facility's policy for subcutaneous injections specifically instructed staff to perform hand hygiene after glove removal, but this step was omitted. Additionally, staff did not adhere to enhanced barrier precaution protocols for residents with complex medical needs. For a resident with an ileostomy, a registered nurse washed hands and donned gloves before emptying the ileostomy container but failed to put on a gown as required by the posted enhanced barrier precaution signage. The nurse acknowledged awareness of the protocol but did not follow it during the observed care activity. A similar lapse occurred with a resident who had a urinary catheter and required enhanced barrier precautions. A certified nurse aide washed hands and wore gloves to empty the urinary catheter container but did not wear a gown as directed by the signage. In another case, an LPN entered the room of a resident with a gastrostomy tube and did not perform hand hygiene before entering or after exiting the room, despite the enhanced barrier precaution requirements. In each instance, staff acknowledged the missed steps when interviewed immediately after the observations.