Failure to Follow Enhanced Barrier Precautions and Infection Control During Resident Care
Penalty
Summary
Surveyors identified a failure to maintain infection control practices during incontinence and wound care for one resident. The resident, who had diagnoses including dysphagia, polyneuropathy, and a gastrostomy, required substantial assistance for mobility and personal hygiene. The care plan indicated the resident was at risk for complications related to a PEG site infection and required Enhanced Barrier Precautions (EBP), including the use of gowns and gloves during high-contact care activities such as dressing, hygiene, and wound care. During observation of incontinence care, two CNAs provided care without donning isolation gowns, despite the resident's care plan and facility policy requiring gown and glove use for high-contact activities under EBP. One CNA stated gowns were only necessary for residents with a Foley catheter, while the other was unaware of the requirement. This demonstrated a lack of adherence to established infection control protocols for residents requiring EBP. Additionally, an LPN performed wound care on the resident's PEG tube site without following proper hand hygiene or glove-changing procedures. The LPN used the same gloves to clean the soiled wound and to apply a sterile dressing, without washing hands or using hand sanitizer between steps. The DON confirmed that sterile technique was not used as ordered and that clean technique, including hand hygiene and glove changes, should have been followed. Facility policies reviewed by surveyors outlined the correct procedures, which were not adhered to during the observed care.