Failure to Consistently Implement Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to consistently implement proper hand hygiene and use of personal protective equipment (PPE) during resident care activities. In one instance, a nursing assistant did not perform hand hygiene after removing gloves and before exiting a resident's room, subsequently touching a door handle and attempting to enter another room. The nursing assistant acknowledged not performing hand hygiene and recognized the importance of this practice to prevent the spread of germs. Facility policies required handwashing before and after resident care, but these were not followed in this case. Another deficiency was observed regarding the use of Enhanced Barrier Precautions (EBP) for a resident with an indwelling catheter and a stage four pressure ulcer. Although signage and supplies for EBP were present, a nursing assistant provided peri-care and catheter care while wearing gloves but not a gown, despite coming into contact with the resident and their environment. Multiple staff interviews confirmed that gowns and gloves should be used for residents on EBP, but it was reported that gowns were rarely used, and staff often did not follow posted precaution guidance. The infection preventionist and other staff members acknowledged that compliance with EBP protocols was lacking, with staff frequently neglecting to wear gowns as required. The facility's EBP policy specified that gowns and gloves should be worn during high-contact care activities for residents at increased risk for multidrug-resistant organisms (MDROs), such as those with wounds or indwelling devices. Despite repeated education, staff did not consistently adhere to these protocols, resulting in the observed deficiencies.