F0880

E

Failure to Implement Enhanced Barrier Precautions and Proper Hand Hygiene During Wound and Incontinent Care

Corpus Christi, Texas Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program, including proper implementation of Enhanced Barrier Precautions (EBP) and hand hygiene practices. Surveyors identified that 12 residents were on EBP, yet multiple rooms on several halls, including the room of Resident #50, had PPE containers but no EBP signage posted on the doors or walls outside the rooms. The facility’s own EBP policy required signs to be posted on the door or wall outside the resident room indicating the type of precautions and PPE required. The DON stated she believed signs posted inside the rooms were sufficient and did not realize they also had to be posted outside the rooms.

Resident #50 was a female resident with sepsis, congestive heart failure, and wasting syndrome, with an admission MDS showing moderately impaired cognition (BIMS score of 10), dependence in toileting hygiene, an indwelling catheter, and at least one unhealed pressure ulcer. Her care plan documented a stage 3 sacral wound and a Foley catheter related to skin breakdown. During an observation of wound and incontinent care for this resident, the WCN did not perform hand hygiene or change gloves when moving from dirty to clean tasks. Specifically, the WCN failed to sanitize hands and don clean gloves before re-entering a package of clean wipes, and did not perform hand hygiene or change gloves after touching a urine- and feces-soaked brief during wound care.

The WCN also applied an inadequate amount of hand sanitizer and did not rub her hands long enough to allow the sanitizer to dry before putting on gloves, contrary to product directions. She cleansed the sacral wound from the outside to the inside, wiping from top to bottom, instead of working from the inside to the outside (clean to dirty) in a circular motion. After wound care, both the WCN and CNA-H re-entered the clean container of wipes with contaminated gloves while performing incontinent care. CNA-H continued incontinent care and placed a clean brief under the resident without changing gloves or performing hand hygiene until all care was completed, and then carried the container of wipes, which had been accessed with contaminated gloves, out of the resident’s room. In interviews, the WCN, DON, NP, and CNA-H acknowledged that these practices, including re-entering clean supplies with contaminated gloves and handling dirty briefs during wound care without hand hygiene, could cause cross-contamination and contribute to infection and wound worsening. Record review showed the facility had existing policies on EBP, perineal care, and hand hygiene, as well as an in-service on standard precautions and glove use, which required glove changes and hand hygiene between tasks and when moving from soiled to clean body sites.

In addition, CNA-H reported not recalling being in-serviced on hand washing and glove changes between tasks on the same resident when going from dirty to clean. The NP stated that the observed failures in hand hygiene and wound care technique, including performing wound care while the resident remained in a urine-soaked brief with feces and touching the brief during wound care, could contribute to cross-contamination and wounds not healing or worsening. The DON confirmed that staff were not supposed to take items into the rooms of residents on precautions and then bring them back out, and that re-entering a package of clean wipes with gloves contaminated by urine and feces, as well as improper wound cleaning technique and failure to change gloves after touching a dirty brief, could cause cross-contamination and lead to infection and worsening of wounds.

Record review of the facility’s policies showed that EBP required signs on the door or wall outside the resident room indicating the type of precautions and PPE required, that perineal care procedures required removal of heavily soiled items, glove removal, handwashing, and then new hand hygiene and gloves before proceeding, and that hand hygiene was required before touching a resident, before aseptic tasks, after contact with body fluids or contaminated surfaces, before moving from a soiled to a clean body site on the same resident, and immediately after glove removal. The in-service on standard precautions and glove use required clean gloves to be put on between tasks and procedures involving the same resident. The observed practices by the WCN and CNA-H, and the lack of required EBP signage outside resident rooms, were inconsistent with these written policies and contributed to the cited infection control deficiency.

Interviews further clarified staff understanding and acknowledgment of the issues. The WCN stated she knew which residents were on EBP from the chart and a sign inside the room, but was unsure about the requirement for signage outside the room, though she agreed it would make sense so anyone entering would know the proper PPE to use. She also acknowledged she should have ensured the resident had a clean brief before wound care, should not have touched the dirty brief during wound care, and that her wound cleaning technique and re-entering clean wipes with contaminated gloves could have caused cross-contamination and infection. CNA-H acknowledged that reaching into a clean wipes container with contaminated gloves and touching clean linens or briefs with dirty gloves could cause cross-contamination. These observations and statements formed the basis of the surveyors’ finding that the facility failed to maintain an effective infection prevention and control program for all residents reviewed for infection control practices.