Failure to Adhere to Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for two residents on Enhanced Barrier Precautions (EBP). For one resident with a history of multidrug-resistant organism (MDRO), both an LPN and a CNA entered the resident's room to assist with a mechanical lift transfer and other care activities without donning required gowns, although they wore gloves and performed some hand hygiene. The resident's care plan and EBP signage indicated that gowns and gloves were required for close contact care, but staff did not comply. The LPN acknowledged that transferring and adjusting the resident, as well as changing oxygen equipment, constituted high-contact care requiring full PPE, and the CNA stated she only wore a gown during showers, not for other care activities. For another resident with a history of ESBL in urine, a CNA performed incontinent care without wearing a gown and failed to perform hand hygiene between glove changes. The CNA wore gloves but did not sanitize hands between glove changes, despite handling soiled briefs and cleaning the resident. The CNA later stated she misunderstood the EBP signage, believing it applied to the roommate, and noted that the hand sanitizer dispenser was outside the room. The resident's care plan and facility policy required proper PPE use and hand hygiene for all staff providing care to residents on EBP. Interviews with the ADON, who also served as the Infection Preventionist, and the DON confirmed that their expectations were for staff to wear appropriate PPE and perform hand hygiene during all close contact care for residents on EBP. Facility policies reviewed also required hand hygiene before and after resident contact and after glove removal, as well as adherence to PPE requirements based on transmission-based precautions.