Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to follow its enhanced barrier precautions (EBP) policy and did not ensure staff consistently donned appropriate personal protective equipment (PPE) or performed hand hygiene as required during direct resident care. Certified nurse aides (CNAs) and nursing staff were observed entering rooms of residents on EBP without donning gowns, handling resident items, and providing care such as incontinence care and wound care without following PPE protocols. Staff were also seen exiting resident rooms and handling equipment or soiled linen carts before performing hand hygiene, contrary to facility policy and posted signage. Several residents were affected by these lapses. One CNA entered a resident's EBP room, rearranged personal items, and handled the resident's water pitcher without donning a gown or performing hand hygiene before leaving the room. Another CNA provided incontinence care to a resident on EBP without a gown and failed to perform hand hygiene before exiting the room and handling soiled linens. A wound care nurse provided wound care to a resident with a pressure ulcer requiring a dressing without donning a gown, despite facility signage indicating that any skin care requiring a dressing necessitates EBP. Additionally, a nurse provided colostomy care to a resident on EBP without donning a gown. Interviews with staff revealed confusion and misinterpretation of the EBP policy, with some staff believing that EBP should only be implemented for wounds present for 90 days or more, despite facility policy and CMS guidance indicating that EBP applies to any resident with wounds or indwelling medical devices. The infection prevention nurse was unaware of the specific requirements posted on EBP signage, and staff acknowledged that hand hygiene should be performed before exiting any resident room, which was not consistently done. Medical records confirmed the presence of wounds requiring dressings in affected residents, further supporting the need for EBP.