Failure to Follow PPE and Hand Hygiene Protocols During PEG Tube Care
Penalty
Summary
Staff failed to follow infection prevention and control protocols during the care of a resident with a percutaneous endoscopic gastrostomy (PEG) tube who was on Enhanced Barrier Precautions (EBP). Facility policy required staff to wear gloves during high-contact care activities for residents with indwelling medical devices and to perform hand hygiene before and after direct resident contact, handling invasive devices, and after removing gloves. Despite these requirements, an LPN entered the resident's room without gloves, removed the PEG tube dressing with bare hands, and only applied gloves after this step without performing hand hygiene. The LPN then cleaned the PEG tube site, removed gloves, and redressed the site with ungloved hands, again failing to perform hand hygiene. The EBP signage on the resident's door clearly indicated that gloves were required for feeding tube care. Both the LPN and the Director of Nursing confirmed that proper glove use and hand hygiene were not followed during the procedure. The resident involved had an active order for PEG tube site care and was on EBP with specific interventions for staff to wear gloves.