Failure to Perform Hand Hygiene Before Entering EBP Room
Penalty
Summary
A Certified Nursing Assistant (CNA) entered a room designated for Enhanced Barrier Precautions (EBP) without performing required hand hygiene, either by using alcohol-based hand rub (ABHR) or washing hands. The room was clearly marked as being on EBP, and an ABHR dispenser was available outside the room. The CNA entered to assist a resident with their meal tray and later acknowledged forgetting to use ABHR before entering, despite the resident being on EBP due to an extended-spectrum beta-lactamase (ESBL) urinary tract infection. A Registered Nurse (RN) observed the CNA's failure to perform hand hygiene and confirmed the resident's EBP status due to ESBL in the urine. The facility's policy, updated in March 2024, requires all individuals to clean their hands with ABHR before entering any room on EBP. The Administrator also confirmed that the CNA should have performed hand hygiene prior to entry. The incident was identified through observation, interview, and document review, and the deficiency was noted as having the potential to affect the resident population.