Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed for a resident with a nephrostomy and other complex medical conditions. During care, an LPN emptied the resident's nephrostomy bag while wearing only gloves, without donning a gown as required under enhanced barrier precautions (EBP) for residents with indwelling medical devices. After emptying the bag and disposing of the contents, the LPN removed her gloves and immediately donned a new pair without performing hand hygiene, contrary to facility policy and physician orders that specify hand hygiene before and after glove use. Additionally, a CNA providing incontinence care to the same resident did not change gloves or perform hand hygiene between cleaning the resident and handling clean supplies, such as picking up clean incontinence briefs. Both staff members acknowledged during interviews that they should have performed hand hygiene and changed gloves as required. The Infection Preventionist confirmed that the expectation is for staff to wash hands before starting care and to use gowns and gloves appropriately when providing high-contact care to residents on EBP.