Failure to Follow Hand Hygiene and Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to adhere to its Handwashing/Hand Hygiene policy during wound care for a resident with a sacral wound. During an observed wound care procedure, a nurse entered the resident's room, donned a gown, sanitized her hands, and put on gloves. She removed the soiled dressing from the resident's sacrum and, without changing gloves or performing hand hygiene, proceeded to clean the wound and apply a new dressing. The nurse only removed her gloves and gown and performed hand hygiene after completing the entire procedure. In an interview, the nurse acknowledged forgetting to sanitize or wash her hands between steps and suggested she could have double-gloved, but this was not in accordance with policy. Additionally, the facility did not implement its Enhanced Barrier Precautions (EBP) policy during high-contact care activities for a resident with a chronic wound and a feeding tube. During an observation, a nurse aide and a nurse entered the resident's room to reposition and dress the resident. While the nurse aide donned both a gown and gloves, the nurse only wore gloves, despite EBP signage and a PPE caddy indicating that both gown and gloves were required for high-contact care activities such as dressing. The nurse later stated she was unaware of the EBP signage and believed a gown was only necessary when directly caring for the wound or feeding tube, not for dressing the resident. Interviews with the Director of Nursing, who also served as the Infection Preventionist, confirmed that staff were educated to follow hand hygiene protocols and EBP requirements, including wearing gowns and gloves during high-contact care for residents with wounds or indwelling devices. The administrator also confirmed that staff should wear both gown and gloves during such activities. The observed failures involved two staff members and were not in accordance with the facility's established infection control policies.