Failure to Implement Enhanced Barrier Precautions and Hand Hygiene During High-Contact Care
Penalty
Summary
The facility failed to ensure that direct care staff consistently utilized Enhanced Barrier Precautions (EBP) and adhered to proper hand hygiene and glove use during high-contact care activities for residents with indwelling medical devices, such as urinary catheters and gastrostomy tubes. Observations revealed that staff did not don required personal protective equipment (PPE), including gowns and face shields, when providing care to residents with these devices, despite clear signage and facility policy indicating the necessity of EBP for such situations. For example, staff were observed assisting a resident with a urinary catheter without wearing gowns or face shields, and performed multiple care tasks, including perineal and catheter care, with soiled gloves and without appropriate hand hygiene between tasks. Additionally, staff demonstrated a lack of understanding regarding the purpose and application of EBP. Interviews with CNAs indicated confusion about when and why EBP bins and PPE were to be used, with some staff believing the precautions were only necessary when residents were acutely ill or "had something going on." This misunderstanding led to inconsistent use of PPE and lapses in infection control practices, such as failing to wash hands after glove removal and before donning new gloves, and not changing gloves between dirty and clean tasks. The residents involved had significant care needs and indwelling devices that required strict adherence to infection prevention protocols. One resident had a suprapubic catheter and required EBP during high-contact care, while another had a gastrostomy tube and was dependent on staff for all activities of daily living. Despite these needs, staff did not follow established protocols for EBP and hand hygiene, as evidenced by multiple observed care episodes and staff interviews. The Director of Nursing confirmed that staff were expected to use EBP for residents with relevant signage and devices, but observations and interviews showed this was not consistently practiced.