Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to ensure staff adhered to infection prevention and control practices for two residents requiring Enhanced Barrier Precautions (EBP). For one resident with a PEG tube, a registered nurse did not perform hand hygiene between glove changes and failed to don a gown while administering medications, despite the resident's need for EBP. The nurse acknowledged not following protocol, and both the infection preventionist and acting DON confirmed that hand hygiene and gown use were required by facility policy during such procedures. For another resident receiving wound care, an LPN did not wear a gown and failed to change gloves after cleansing a dirty wound bed, applying a clean dressing with contaminated gloves. The LPN admitted to not following EBP and glove-changing protocols, and the DON and infection preventionist confirmed that these steps were necessary to prevent contamination. Both residents had documented medical needs requiring these precautions, and the facility's own policies outlined the required infection control measures that were not followed.