Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
Nursing staff failed to follow required Enhanced Barrier Precautions (EBP) and hand hygiene protocols during direct care of residents under infection control interventions. In one instance, a licensed nurse prepared wound care supplies for a resident with a pressure ulcer and entered the resident's room without donning a gown as required by EBP status. The nurse also failed to perform hand hygiene before donning gloves, between glove changes, and after completing the wound dressing change. Supplies were placed directly on the resident's bedside table, and the nurse exited the room without washing or sanitizing hands. The nurse later acknowledged not realizing the omission of the gown or hand hygiene steps during the procedure. In another instance, a certified nurse aide entered a resident's room to empty a catheter drainage bag but did not don a gown as required by EBP. The aide placed the catheter drainage bag directly on the floor while obtaining a privacy bag, contrary to facility policy that requires keeping the drainage bag off the floor. Both administrative nurses confirmed that staff are expected to use gowns and gloves during such care and that the drainage bag should not be placed on the floor. Facility policies on infection prevention and indwelling urinary catheters specify the use of standard and transmission-based precautions, including proper hand hygiene and environmental practices.