Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
A certified nursing assistant (CNA) failed to adhere to the facility's infection prevention and control program by not performing hand hygiene between resident rooms. The CNA was observed exiting a resident's room that was under enhanced barrier precautions, carrying a bag of garbage and a water mug. Despite signage requiring hand hygiene upon entry and exit, as well as the use of gowns and gloves for high-contact care, the CNA did not sanitize or wash hands after discarding the garbage and before entering another resident's room. The CNA also did not wear a gown or gloves while providing care to the resident with a wound, contrary to the posted requirements and facility policy. During interviews, the CNA stated that she believed the enhanced barrier precautions were no longer necessary because the resident's wound had healed, and therefore did not follow the required protocols. The Director of Nursing (DON) confirmed that the resident still had a wound and that staff should have been using gowns and gloves when providing care. Review of the facility's Enhanced Barrier Precaution and Hand Hygiene policies, both updated in April 2025, confirmed that staff are expected to comply with these precautions for residents with wounds and to perform hand hygiene between resident contacts and after handling contaminated objects.