Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
Staff failed to follow infection control standards for enhanced barrier precautions during incontinence care for a resident with a gastrostomy tube and a physician's order for enhanced barrier precautions. During an observation, both an LPN and a CNA provided incontinence care to the resident without wearing gowns, despite signage and care plan instructions indicating the need for gown and glove use during high-contact care activities. Both staff members acknowledged in interviews that they were aware of the requirement to wear gowns and gloves but did not do so during the care provided. Additionally, hand hygiene protocols were not followed during multiple medication administration observations. An LPN was observed handling the medication cart, computer, and resident care supplies, as well as entering and exiting resident rooms, without performing hand hygiene at any point before donning gloves, after removing gloves, or between resident contacts. The LPN also failed to perform hand hygiene before and after administering medications, performing blood glucose checks, and handling insulin, despite facility policy and CDC guidelines requiring hand hygiene at these points of care. The resident involved in the enhanced barrier precautions deficiency had a recent admission with medical diagnoses including a gastrostomy tube, and the care plan specifically required enhanced barrier precautions during high-contact care activities due to the presence of an indwelling medical device. Facility policies reviewed confirmed the need for gown and glove use for such residents and outlined the importance of hand hygiene before and after resident contact and invasive procedures. Staff interviews confirmed knowledge of these requirements, but the observed practices did not align with facility policy or infection control standards.