Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple lapses in infection control practices during care provided to two residents. Certified Nursing Assistants (CNAs) did not consistently perform hand hygiene when changing gloves during peri-care and wound care. Specifically, during Foley catheter care for a resident with a stage 4 sacral pressure ulcer and other significant medical conditions, the CNA and Assistant Director of Nursing (ADON) did not don gowns as required by Enhanced Barrier Precautions signage. The CNA also changed gloves without performing hand hygiene, and soiled wipes were observed in a trash bag at the foot of the bed, with some wipes touching the resident's top sheet and the resident's feet coming into contact with the soiled wipes. During wound care for the same resident, the Licensed Vocational Nurse (LVN) and Registered Nurse (RN) donned gowns and gloves as required, but the LVN removed gloves and handled a wound dressing with bare hands before sanitizing and re-gloving. For another resident with colon cancer and a neuromuscular bladder dysfunction, two CNAs provided peri-care without donning gowns, despite Enhanced Barrier Precautions signage. One CNA was observed applying hand sanitizer in a haphazard manner while holding a glove, and then donning the glove without proper hand hygiene. Interviews with the CNA, ADON, and Director of Nursing (DON) confirmed that staff were aware of the requirements for hand hygiene and the use of gowns and gloves during high-contact care activities for residents on Enhanced Barrier Precautions. Facility policies and CDC guidance were reviewed, indicating that hand hygiene and proper use of personal protective equipment (PPE) are required during high-contact care activities, and that supplies should be readily accessible. In-service records showed that the involved CNA had received training on infection control and Enhanced Barrier Precautions prior to the observed deficiencies.