Failure to Adhere to Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to ensure proper implementation of its infection prevention and control program, specifically regarding the use of Personal Protective Equipment (PPE) and hand hygiene. For one resident with multiple comorbidities, including end stage renal disease and an indwelling dialysis catheter, staff did not consistently don both gloves and gowns during high-contact care activities as required by the facility's Enhanced Barrier Precautions (EBP) policy. Observations revealed that a CNA assisted the resident with dressing while wearing gloves but not a gown, and both a physical therapist and a physical therapy assistant provided transferring assistance without donning any PPE, despite clear signage and policy requirements for gown and glove use during such activities. Interviews with staff, including the CNA, physical therapy staff, and the staff development coordinator, indicated a misunderstanding of the EBP policy. Staff believed that gowns were only necessary when providing care directly related to the indwelling device or wounds, rather than for all high-contact activities such as dressing, transferring, and hygiene. This misunderstanding persisted until the infection preventionist reviewed the CDC signage and facility policy, confirming that gowns and gloves were required for all high-contact care for residents on EBP. Additionally, the facility failed to ensure proper hand hygiene during medication administration for another resident with dementia, diabetes, and kidney failure. An LPN was observed preparing and administering insulin without removing gloves or performing hand hygiene between tasks, including after direct resident contact and after glove removal. The LPN confirmed the failure to follow hand hygiene protocols, and the infection preventionist acknowledged the lapse in infection control practices during medication administration.