Failure to Ensure Proper PPE Use and Hand Hygiene for Residents on Enhanced Barrier Precautions
Penalty
Summary
Staff failed to properly use personal protective equipment (PPE) and maintain hand hygiene for residents on enhanced barrier precautions (EBP). For one resident with a suprapubic catheter and MRSA colonization, a registered nurse performed a dressing change without wearing a gown, failed to sanitize hands between glove changes, and used the same gloves to cleanse the catheter site and apply a clean dressing. The nurse acknowledged forgetting to wear a gown and skipping hand hygiene steps due to the location of supplies. For another resident with an indwelling catheter, feeding tube, and MRSA colonization, nursing assistants and a licensed practical nurse inconsistently sanitized hands between glove changes during high-contact care activities, such as incontinence care and feeding tube dressing changes. Staff sometimes applied clean gloves without hand hygiene and did not always change gloves or sanitize hands after cleansing insertion sites. Interviews with staff confirmed awareness of the facility's expectations for PPE use and hand hygiene, but lapses occurred due to forgetfulness or nervousness. Facility policies required hand cleansing before donning gloves, after glove removal, and before moving from soiled to clean body sites, as well as the use of gowns and gloves for high-contact care activities for residents on EBP. Observations and staff interviews demonstrated that these protocols were not consistently followed during resident care.