Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper practices observed during care provided to a resident with a diabetic foot ulcer requiring enhanced barrier precautions (EBP). Two CNAs provided incontinent care to the resident without consistently following EBP protocols. Specifically, one CNA did not sanitize her hands before donning gloves, and both CNAs failed to change gloves and perform hand hygiene when moving from contaminated to clean tasks. Additionally, neither CNA wore a gown as required by EBP policy for high-contact care activities, despite signage and care plan instructions indicating the need for gown and glove use. The resident involved had a history of cerebral infarction with right-sided hemiplegia and type 2 diabetes, and was totally dependent on staff for toileting hygiene, with a documented open wound on the left foot. During the observed care episode, the CNAs performed multiple tasks, including cleaning the resident after a bowel movement and changing briefs, but did not change gloves or sanitize hands between dirty and clean tasks. One CNA also touched clean items, such as linens and the resident's cap, with contaminated gloves. Both CNAs acknowledged during interviews that they were aware of the EBP requirements and hand hygiene protocols but failed to follow them during the care episode. Interviews with facility leadership confirmed that staff had received training on infection control, hand hygiene, and EBP, and that policies required hand hygiene before and after glove use, as well as the use of gowns and gloves for residents on EBP during high-contact care. Documentation showed that at least one CNA had attended recent in-service training on these topics. Despite this, the observed failures in infection control practices placed residents at risk of exposure to infectious diseases due to improper adherence to established protocols.