Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during the provision of care to a resident with a diabetic foot ulcer requiring enhanced barrier precautions (EBP). The resident, who had a history of stroke, hemiplegia, and type 2 diabetes, was totally dependent on staff for toileting and hygiene and was always incontinent of urine and bowel. Physician orders and the care plan specified the use of gown and gloves for EBP during high-contact care activities, such as providing hygiene and changing briefs. On the observed date, both CNAs entered the resident's room to provide incontinent care. One CNA sanitized her hands before donning gloves, while the other did not perform hand hygiene prior to gloving. Neither CNA wore a gown as required by EBP protocols, and both failed to change gloves or perform hand hygiene when moving from dirty to clean tasks during care. Specifically, one CNA continued to use the same gloves after cleaning the resident's perineal area and then handled clean items, such as a new brief and bed linens, without changing gloves or sanitizing hands. Interviews with the CNAs revealed that they were aware of the EBP requirements and hand hygiene protocols but failed to follow them, citing forgetfulness. Facility records confirmed that both CNAs had received training on infection control, EBP, and hand hygiene. Facility leadership, including the DON, ADON, and IP, acknowledged the lapses in protocol and confirmed that the observed care did not meet the facility's infection control policies.