Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident with multiple complex medical needs, including a g-tube, suprapubic catheter, and tracheostomy. The resident was care planned for Enhanced Barrier Precautions (EBP) due to the presence of a catheter. Observations revealed that the Infection Control Preventionist provided oral care to the resident wearing only gloves and no gown, contrary to EBP requirements. Additionally, a registered nurse performed multiple dressing changes on the resident's wounds, catheter, g-tube, and tracheostomy without changing gloves or performing hand hygiene between sites, as required by facility policy. Further observation showed the same nurse administering medication via the resident's g-tube without wearing gloves or a gown. Review of facility policies confirmed that EBP requires gown and glove use during high-contact care activities, including device care and wound care, and that hand hygiene must be performed after handling contaminated objects and between dressing changes. The Infection Control Preventionist acknowledged these lapses in infection control practices during an interview.