Failure to Perform Hand Hygiene for Resident on Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently performed hand hygiene as part of its infection prevention and control program for a resident on Enhanced Barrier Precautions (EBP). The resident had multiple serious infections and conditions, including a urinary tract infection, unspecified Escherichia coli as the cause of disease, cellulitis of the buttock, local skin and subcutaneous tissue infection, resistance to multiple antimicrobial drugs, a stage 4 pressure ulcer of the right buttock, and Clostridium perfringens as the cause of disease. An EBP sign was posted outside the resident’s room. During observation, the Director of Staff Development (DSD) entered the resident’s room in response to a call light without performing hand hygiene, turned off the call light, and exited the room without performing hand hygiene. The DSD acknowledged not performing hand hygiene upon exiting the EBP room and stated that hand hygiene was supposed to be performed to prevent the spread of infections in the facility. In a separate observation, a Certified Nurse Assistant (CNA) picked up a meal tray from the meal cart in the hallway, entered the same resident’s room, delivered the tray, placed it on the over-bed table, and assisted with meal preparation, then exited the room and approached the meal cart without performing hand hygiene. The CNA stated she forgot to perform hand hygiene after exiting the room and before handling another resident’s meal tray, and acknowledged that this failure placed other residents at risk for infection. The Infection Prevention Nurse stated that staff were required to perform hand hygiene before entering and after exiting a resident’s room and before and after performing any task for residents, and that failure to do so placed other residents at risk for infection. The DON stated that staff were required to perform hand hygiene as part of standard precautions to break the infection cycle and prevent the spread of infection. Facility policies on Enhanced Barrier Precautions and Infection Control Guidelines for All Nursing Procedures required visual alerts for high-contact care and hand hygiene after contact with objects in the immediate vicinity of the resident.
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