Failure to Adhere to Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
Staff failed to don appropriate personal protective equipment (PPE), specifically gowns, when providing care to residents on enhanced barrier precautions (EBP). For one resident with cerebral atherosclerosis, tracheostomy, and gastrostomy, an LPN provided care without wearing a gown despite an active EBP order. In another instance, wound care was performed for two residents with stage three pressure ulcers and other significant diagnoses, but staff did not don gowns as required by EBP signage and orders. Staff interviews confirmed awareness of the EBP requirements but acknowledged non-compliance during care activities. Additionally, staff did not consistently practice proper hand hygiene. An LPN failed to perform hand hygiene after administering medication to one resident and before administering medication to another. During wound care for a resident with multiple complex conditions, staff removed gloves after care but exited the room without performing hand hygiene. Facility policies reviewed indicated that hand hygiene should occur before and after resident contact, after glove removal, and that staff should consult with nursing to determine appropriate PPE for transmission-based precautions.