Failure to Follow Infection Control Protocols During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in hand hygiene, improper use of personal protective equipment (PPE), and inappropriate handling of a urinary collection bag for a resident on enhanced barrier precautions. During incontinence care, a Licensed Practical Nurse (LPN) was observed wearing only gloves, without a gown, while providing care to a resident with an indwelling urinary catheter and enhanced barrier precautions in place. The LPN also handled the resident’s urinary collection bag, which was found lying directly on the floor and partially under the bed’s stabilizing section, contrary to facility policy and CDC guidelines. The LPN did not perform hand hygiene before leaving the resident’s room after completing care tasks. Further observations revealed that a Certified Nursing Assistant (CNA) failed to remove gloves and perform hand hygiene after blowing her nose and after providing perineal care involving exposure to fecal matter. The CNA continued to perform additional care tasks, such as applying cream and repositioning the resident, without changing gloves or washing hands. Both the LPN and CNA did not consistently follow the facility’s policies regarding hand hygiene and the use of gowns and gloves during high-contact care activities for residents on enhanced barrier precautions. The resident involved had multiple medical conditions, including hypertension, lumbar radiculopathy, osteoarthritis, benign prostatic hyperplasia, obstructive and reflux uropathy, and anxiety disorder. The resident required substantial assistance with toileting and hygiene and had an indwelling urinary catheter, necessitating enhanced barrier precautions. Despite clear facility policies and physician orders for the use of gowns and gloves during high-contact care, staff did not adhere to these protocols, resulting in a failure to reduce the risk of disease and infection transmission.