Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Incontinence Care
Penalty
Summary
Staff failed to follow the facility's infection prevention and control program by not donning all required personal protective equipment (PPE) and not adhering to hand hygiene protocols during incontinence care for a resident with an indwelling urinary catheter. Facility policy required Enhanced Barrier Precautions (EBP), including the use of gloves and gowns, for residents with catheters during high-contact care activities. Despite visible signage and available gowns outside the resident's room, staff only donned gloves and did not wear gowns while providing care. During the observed care, two staff members assisted the resident, who had a history of infection and required assistance with personal care. Both staff members performed incontinence care without changing gloves between dirty and clean tasks, and handled personal items and clean clothing with soiled gloves. Hand hygiene was not performed at appropriate intervals, and gloves were only changed after multiple care steps had been completed. The staff members acknowledged during interviews that they should have worn gowns and changed gloves more frequently, but cited uncertainty and nervousness as reasons for their actions. Interviews with facility leadership, including the QA/Infection Prevention Nurse, ADON, DON, and Administrator, confirmed that the expectation was for staff to wear gowns and gloves for residents on EBP and to change gloves when soiled or before handling clean items. Monitoring of staff compliance was described as a responsibility of the QA/IP Nurse and nursing leadership, but there was uncertainty about who specifically monitored incontinence care. The deficiency was identified through direct observation, interviews, and review of facility policy.