Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Wound Care
Penalty
Summary
Staff failed to follow Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols during wound care for two residents. In one instance, two licensed nurses provided wound care to a resident with a Stage 2 pressure ulcer without following EBP guidelines, such as wearing gowns and changing gloves at appropriate times. The care plan for this resident did not include specific instructions for EBP or the required personal protective equipment (PPE), and a certified nurse aide was unaware that EBP was necessary for this resident. The resident had multiple diagnoses, including Alzheimer's disease, COPD, hemiparesis, and was dependent on staff for all activities of daily living. In another case, wound care for a resident with a Stage 4 pressure ulcer was performed without the use of protective gowns, and hand hygiene was not consistently performed between glove changes or after glove removal. One nurse applied clean gloves without performing hand hygiene, failed to don a gown, and did not sanitize hands after removing gloves or handling trash. The facility's policies required the use of gowns and gloves for high-contact care activities and specified hand hygiene before and after glove use, but these protocols were not followed during the observed care. Additionally, the facility failed to ensure that a resident's nasal cannula and nebulizer mask were properly stored when not in use, which could contribute to infection risk. The facility's own policies on EBP and hand hygiene were not adhered to during these care activities, as evidenced by staff statements and direct observation.