Failure to Ensure Proper Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper hand hygiene during wound care for two residents. Observations revealed that registered nurses did not consistently perform hand hygiene when changing gloves between wound care tasks. Specifically, one nurse washed hands before starting wound care and after completion, but did not perform hand hygiene each time gloves were changed, despite changing gloves multiple times during the procedure. Another nurse also failed to perform hand hygiene between glove changes, only doing so at the beginning and end of the wound care process. Interviews with the nurses and the director of nursing confirmed inconsistent understanding and implementation of hand hygiene protocols, with some staff believing that changing gloves was sufficient without hand hygiene unless hands were visibly soiled. The facility also failed to properly implement Enhanced Barrier Precautions (EBP) for four residents who required contact precautions due to conditions such as stage 4 pressure ulcers, indwelling catheters, diabetic foot wounds, and gastrostomy tubes. Observations showed that rooms for these residents lacked signage indicating the need for precautions and did not have visible storage for personal protective equipment (PPE). Interviews with residents and family members indicated a lack of awareness or recall regarding the negotiated risk agreements that were signed to opt out of EBP, and some did not remember being educated about the risks or the precautions required for their conditions. Facility documentation indicated that all residents who qualified for EBP had signed negotiated risk agreements to opt out of these precautions, as confirmed by the director of nursing. However, interviews revealed that the process for presenting and explaining these agreements was unclear, and residents or their representatives often did not recall the information being reviewed with them. The facility's policy required a risk assessment for EBP on all new admissions, but the observed lack of signage, PPE availability, and inconsistent education contributed to the failure to implement EBP as recommended.