Failure to Follow Hand Hygiene and Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene and adherence to enhanced barrier precautions (EBP) during wound care for a resident. During an observed wound care procedure, an LPN did not wear a gown as required by the facility's EBP policy and did not perform hand hygiene after removing gloves and before donning new gloves. Instead, the LPN reached into her pocket to put on new gloves and continued with the wound care process, including cleaning the wound and applying medication and dressings, without using hand sanitizer or washing hands as required by both facility policy and CDC/CMS guidelines. The resident involved had a diagnosis of dementia and required staff assistance for daily care needs, including treatment for a sacral pressure ulcer. Physician orders specified daily wound care, and the facility's policies, as well as updated CDC and CMS guidance, required the use of gowns and gloves during high-contact care activities for residents with wounds, regardless of MDRO status. Interviews with the LPN and the Nursing Home Administrator confirmed that the required infection control practices were not followed during the observed wound care event.