Failure to Follow Infection Control and Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to adhere to infection prevention and control standards during personal care for three residents. In one instance, two CNAs provided perineal care to a resident soiled with bowel movement. After removing soiled gloves, one CNA applied new gloves without performing hand hygiene, then continued with resident care tasks before eventually performing hand hygiene. In another case, a CNA removed a resident's soiled brief, performed perineal care, and repeatedly changed gloves without performing hand hygiene between glove changes, only sanitizing hands at the end of the care process. For a resident with a history of osteomyelitis and staphylococcus infection, and who had a PICC line requiring Enhanced Barrier Precautions (EBP), both a CNA and a nurse entered the resident's room without performing hand hygiene or donning PPE. The staff assisted the resident with transfers and toileting, touching the resident, equipment, and room surfaces without following EBP protocols. The nurse later acknowledged the failure to perform hand hygiene and use PPE as required.