Failure to Follow Hand Hygiene, Glove Use, and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to perform appropriate hand hygiene after assisting residents and while preparing and serving food. Observations included a staff member assisting a resident to a dining table, touching the resident, and then serving coffee to multiple residents without performing hand hygiene between contacts. Another staff member was seen feeding two residents alternately without any hand hygiene during the meal, and a third staff member assisted three residents with their meals after moving a stool with bare hands, again without performing hand hygiene. The facility also failed to implement enhanced barrier precautions (EBP) for a resident with a chronic wound. The resident was observed with a wound dressing on her left foot, and staff assisted her with transfers and personal care without wearing an isolation gown, despite facility policy requiring EBP for residents with chronic wounds during high-contact care activities. Interviews revealed confusion among staff regarding which residents required EBP and when to use personal protective equipment (PPE). Additionally, staff did not follow proper glove use and hand hygiene protocols during food preparation. One staff member was observed wearing a glove on one hand while cooking, then using the same gloved hand to handle ready-to-eat food, touch various surfaces, and handle soiled items before removing the glove. Facility policies required hand washing before donning gloves, changing gloves as often as hands need to be washed, and not using the same gloves for multiple tasks, but these procedures were not followed.