Infection Control Deficiencies: Hand Hygiene, PPE, and Enhanced Barrier Precautions
Penalty
Summary
Multiple deficiencies were identified in the facility's infection prevention and control practices, particularly regarding hand hygiene, glove use, and adherence to enhanced barrier precautions (EBP). Staff were observed failing to remove gloves and perform hand hygiene after providing incontinence care, emptying ostomy bags, and before touching clean surfaces or equipment. For example, after emptying a resident's ileostomy bag, a staff member did not remove gloves or perform hand hygiene before turning on the resident's radio. In another instance, a staff member did not remove gloves or wash hands after providing incontinence care, only performing hand hygiene at the end of the care process. There were also failures to use appropriate personal protective equipment (PPE) as required by the facility's EBP policy. Staff were observed not wearing gowns when providing high-contact care activities, such as transferring, changing linens, and providing hygiene to residents on EBP, including those with indwelling urinary catheters or chronic wounds. In one case, a staff member entered a resident's room on EBP, delivered meal trays, and left the room without performing hand hygiene as required by posted signage and facility policy. Additionally, a nurse was observed performing wound care without changing gloves and performing hand hygiene between dirty and clean tasks, contrary to accepted standards and state guidance. The residents involved had significant medical needs, including severe cognitive impairment, incontinence, indwelling urinary catheters, chronic wounds, and pressure ulcers. The observed lapses in infection control occurred during routine care activities such as incontinence care, wound care, catheter care, and assistance with activities of daily living. These actions and inactions were directly observed by surveyors and confirmed through interviews with facility staff, who acknowledged the required procedures were not followed in these instances.