F0880

E

Failure to Follow Hand Hygiene, Incontinence Care Technique, and Enhanced Barrier Precautions

Saint Louis, Missouri Survey Completed on 11-17-2025

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene, incontinence care technique, and use of Enhanced Barrier Precautions (EBP). Review of facility policies showed that staff were required to perform hand hygiene at key points during care, use clean surfaces of wipes for each stroke, cleanse the perineal area from front to back including the genital and anal areas, and change gloves with hand hygiene between dirty and clean tasks. The EBP policy required gown and glove use for high-contact resident care activities such as dressing, transferring, providing hygiene, changing briefs/toileting, and wound care for residents with wounds or indwelling devices, with appropriate signage indicating required PPE and high-contact activities.

Multiple observations showed staff did not follow these policies during incontinence care. One resident who was always incontinent of bowel and bladder and dependent on staff for personal hygiene had peri-care performed by a CNA who double-gloved, removed only one pair of gloves after cleaning stool, did not perform hand hygiene, then applied barrier cream and a clean brief and adjusted the resident’s pillow while wearing the same soiled gloves. Another resident with severe cognitive impairment, frequent incontinence, and limited mobility was found sitting with feet in a puddle of urine and reported being wet all night; during care, the CNA wore the same gloves throughout, wiped only the buttocks with disposable wipes, did not cleanse the front genital or anal areas, and then dressed and transferred the resident without changing gloves or performing hand hygiene. A third resident, cognitively intact but fully dependent for toileting, reported being left soiled; the CNA providing care did not wear a gown, used the same side of a wet washcloth for multiple wipes to the groin without cleansing the genital or anal areas, then applied a clean brief, handled linens, and adjusted the bed while wearing the same gloves, and left the room without performing hand hygiene.

Surveyors also observed failures to implement EBP requirements for residents with wounds. One resident with dementia, a stage 3 heel pressure ulcer, and an EBP order had only a red magnet on the door that did not specify PPE or high-contact activities; a CNA provided incontinence care and dressing without a gown, and later the Wound Practitioner and wound nurse performed wound care on heel and foot eschar without gowns, using only gloves. Another resident with severe cognitive impairment, multiple comorbidities, incontinence, and EBP orders for wounds had a similar red magnet lacking PPE details; a CNA donned gloves in the hallway, provided full incontinence care, dressing, and mechanical lift preparation without changing gloves or performing hand hygiene, and neither the CNA nor the Activities Director wore gowns during the mechanical lift transfer. The Wound Practitioner and wound nurse later performed wound care on this resident’s buttocks wound with gloves only, no gowns.

Additional EBP lapses were observed for other residents with wound-related EBP orders. One cognitively intact resident with a weeping right shin wound on EBP had wound care performed by the wound nurse using gloves only, without a gown, despite active drainage and dressing application. Another resident with severe cognitive impairment and a stage 3 pressure ulcer on EBP had wound care to a buttocks wound performed by the Wound Practitioner and wound nurse wearing gloves but no gowns. Interviews with CNAs, CMTs, nursing staff, the wound nurse, ADON, DON, and the Administrator revealed inconsistent understanding of EBP indications, the meaning of the red door magnets, and required PPE. Some staff believed EBP meant only glove use or associated the red magnet with oxygen use, while others stated that gowns and gloves should be used for all hands-on or high-contact care for residents with wounds. Leadership staff stated expectations that hand hygiene be performed when entering and exiting rooms and between dirty and clean tasks, that peri-care include cleaning all potentially soiled areas including genitals, and that gowns and gloves be used for EBP residents during high-contact care and wound care, which contrasted with the observed practices.