Failure to Follow Hand Hygiene, Glove Use, and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves failures in infection prevention and control practices during resident care, including improper glove use, lack of hand hygiene, and failure to implement ordered enhanced barrier precautions (EBP). During incontinence care for Resident C, two CNAs removed a wet brief and provided perineal care while wearing gloves, then one CNA applied a new brief, opened a bedside table drawer, retrieved and applied a tube of cream to the perineal area, and returned the tube to the drawer without changing gloves. The CNA then removed gloves, donned new gloves from a pants pocket without performing hand hygiene, and, along with the other CNA, repositioned the resident and adjusted the pillow before finally removing gloves and washing hands. In a separate observation involving Resident D, a CNA removed a soiled brief, provided perineal care, and removed a soiled draw sheet, then removed gloves and put on new gloves without performing hand hygiene. The CNA then held a clean sheet against his scrub top while rolling and placing it under the resident, applied a new brief, and, together with another CNA, adjusted the resident and pillow before removing gloves and performing hand hygiene. Another deficiency occurred with Resident F, who had a physician order for EBP after a positive methicillin-resistant Staphylococcus aureus (MRSA) nare swab at the hospital and documentation that the resident was colonized and to be placed in EBP. During observed assistance of Resident F from bed to the restroom and back, a CNA and an LPN did not wear gowns or implement EBP while providing this personal care. Although PPE supplies were present in the resident’s restroom, there was no signage indicating that EBP was required for the resident. An LPN later indicated that the resident had recently received an order for EBP and that a sign was still needed in the room to indicate to staff that PPE should be used for all personal care, as the physician’s order did not specify particular care tasks.
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