Failure to Perform Hand Hygiene and Adhere to Enhanced Barrier Precautions
Penalty
Summary
Multiple instances of non-compliance with infection prevention and control protocols were observed among staff providing care to residents. Certified Nursing Assistants (CNAs) and Registered Nurses (RNs) failed to perform hand hygiene before and after glove use, and did not change gloves between different care activities. For example, a CNA emptied a resident's urine drainage bag, did not clean the spout, and proceeded to perform perineal care, handle personal items, and touch environmental surfaces such as door knobs and wheelchairs, all while wearing the same soiled gloves and without performing hand hygiene. Another CNA provided incontinence care, then assisted with dressing and bed adjustments, again without changing gloves or performing hand hygiene. In several cases, staff exited resident rooms and immediately interacted with other residents or handled clean items without appropriate hand hygiene, increasing the risk of cross-contamination. Staff also failed to adhere to Enhanced Barrier Precautions as required for residents with indwelling medical devices. In one instance, a CNA performed catheter care for a resident with a history of urinary tract infections and an order for enhanced barrier precautions, but did not wear a gown as required. The signage at the room entrance instructed staff to wear both gown and gloves, but this protocol was not followed. Additionally, after providing perineal care and handling soiled materials, the CNA continued to use the same gloves to apply a clean incontinence brief, further breaching infection control standards. Interviews with facility leadership, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and Infection Preventionist (IP), confirmed that staff are expected to perform hand hygiene before and after glove use, clean equipment such as urine bag spouts after emptying, and wear appropriate personal protective equipment (PPE) according to enhanced barrier precautions. Despite these expectations and existing facility policies, direct observations revealed repeated failures to follow these protocols during resident care activities, including wound care, gastrostomy tube flushes, and meal tray distribution.