Failure to Follow Enhanced Barrier Precautions and Infection Control Protocols
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in standard and enhanced barrier precautions by staff caring for a resident with significant medical needs. The resident in question was a female with a history of dependence on renal dialysis, chronic kidney disease, encephalopathy, and cirrhosis of the liver, and had an intravenous access device for hemodialysis. She was placed on enhanced barrier precautions due to her medical devices and multiple wounds. Observations revealed that soiled gloves, gowns, and linens were left inappropriately in the resident's room, including on the floor and on top of furniture, rather than being immediately bagged and removed to designated areas. A CNA entered the room without performing hand hygiene or donning appropriate PPE, handled soiled linens, and then transported contaminated items into another resident's room before disposing of them, contrary to facility policy and infection control standards. Interviews with the involved CNA confirmed that she did not follow proper infection control procedures, including failing to wear a gown and gloves when handling soiled linens and not immediately removing contaminated items from the resident's room. The CNA admitted to being in a hurry and acknowledged the risk of infection transmission due to her actions. She also confirmed that she had received in-service training on enhanced barrier precautions and infection control but could not recall the date. The Infection Control Nurse corroborated that the CNA's actions were not in line with facility protocols, emphasizing that soiled linens and garbage should not be left in resident rooms or transported through other resident areas, and that staff must wear appropriate PPE and perform hand hygiene when caring for residents on enhanced barrier precautions. A second CNA was observed entering the same resident's room to provide toileting assistance without performing hand hygiene before donning PPE. She touched her clothing and the outside and inside of gloves with unwashed hands before providing care. In an interview, this CNA also acknowledged the lapse in infection control practices and the potential for cross-contamination. The Director of Nursing confirmed that staff are expected to follow strict hand hygiene and PPE protocols, and that soiled linens and garbage must be handled and disposed of according to infection control policies. Facility policy on enhanced barrier precautions was reviewed and outlined the required use of gowns and gloves during high-contact care activities, which was not followed in these instances.