Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
Surveyors identified that the facility failed to maintain an effective infection prevention and control program for two of five residents reviewed. For one resident with multiple medical conditions, including a PICC line, Foley catheter, and a wound requiring a wound vac, staff did not adhere to enhanced barrier precautions as required. Certified Nurse Aides provided hands-on care, such as bathing, turning, and catheter care, while wearing gloves but not gowns, despite signage and facility policy mandating both gown and glove use for high-contact activities. Interviews with staff revealed a lack of understanding regarding the specific requirements of enhanced barrier precautions and the appropriate use of personal protective equipment (PPE) based on the type of precaution indicated. In another instance, a resident dependent on staff for toileting and hygiene care received fecal incontinence care from a Certified Nurse Aide who failed to remove gloves and perform hand hygiene before handling clean briefs, applying barrier cream, and touching clean linens and the bed remote. This action was contrary to the facility's hand hygiene policy, which requires glove removal and hand hygiene after contact with bodily fluids and before handling clean items. The staff member acknowledged during interview that they should not have touched clean items with contaminated gloves, recognizing the risk of cross-contamination. Further interviews with nursing staff, including LPNs and the Director of Nursing, confirmed that the expectation was for staff to follow enhanced barrier precautions and proper hand hygiene protocols to prevent the spread of infection. The deficiency was attributed to staff not consistently following established infection control policies, including the use of PPE and hand hygiene practices during resident care activities involving high risk for transmission of communicable diseases.