Failure to Adhere to Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to consistently follow infection prevention and control protocols for residents on Enhanced Barrier Precautions (EBP). In one instance, a CNA entered a resident's room, applied gloves, assisted the resident, removed gloves, and then transported the resident to the dining room without performing hand hygiene before or after glove use. The same CNA then handled another resident's meal tray and proceeded to provide care to a different resident, again without performing hand hygiene. Facility policy requires hand hygiene before and after glove use and after contact with inanimate objects in the resident's vicinity. Additionally, staff did not properly use or remove personal protective equipment (PPE) as required for residents on EBP. One CNA exited a resident's room while still wearing PPE, retrieved a blanket from the hallway, and re-entered the room, contrary to facility policy that mandates removal of PPE before exiting the room. In another case, two CNAs provided perineal care to a resident with multiple chronic wounds while only wearing gloves and not gowns, despite policy requiring both gown and gloves for high-contact care activities for residents on EBP. Interviews with staff and review of facility policies confirmed these practices were not in accordance with established infection control procedures.