F0880

E

Failure to Follow Hand Hygiene and Enhanced Barrier Precautions During Resident Care

Bertram, Texas Survey Completed on 11-26-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to hand hygiene during peri-care and implementation of Enhanced Barrier Precautions (EBP) for a resident with a surgical wound. For one male resident with parkinsonism, bone density disorder, chronic atrial fibrillation, depression, bladder and bowel incontinence, and risk for UTIs, a CNA provided peri-care without sanitizing her hands between glove changes and without changing gloves between cleaning the front and back perineal areas. The CNA also repeatedly touched the package of wipes with contaminated gloves before changing them. The CNA later stated she had received monthly training on hand hygiene and peri-care, knew she should sanitize her hands every time she changed gloves and between front and back peri-care, and acknowledged she forgot to do so.

For a female resident with Alzheimer’s disease, major depressive disorder, type 2 diabetes, muscle weakness, bladder and bowel incontinence, and a care plan requiring staff to provide peri-care after each incontinent episode, a CNA performed peri-care without sanitizing her hands or changing gloves between cleaning the front and back perineal areas. After completing peri-care, the CNA did not remove the contaminated gloves and proceeded to assist the resident back into her wheelchair, then pushed the wheelchair into the hallway while touching the doorknob with the same contaminated gloves. In an interview, this CNA reported she had been trained on hand hygiene and peri-care the prior week and stated she should remove gloves after completing peri-care and wash hands before touching anything else in the resident’s environment, and that not cleaning hands and not changing gloves would spread infection to other residents.

For another female resident with dementia, muscle weakness, Down syndrome, and a care plan requiring peri-care and application of barrier creams after every incontinent episode, two CNAs provided peri-care and changed gloves without performing hand hygiene. One CNA did not remove gloves before reaching for the side table, opening a drawer, and taking out barrier cream, then applied the cream to the resident’s skin while still wearing the same gloves. Both CNAs stated they had been trained on hand hygiene and were supposed to wash their hands between glove changes, avoid touching furniture with contaminated gloves, and change gloves and perform hand hygiene between front and back peri-care areas and when gloves became soiled. One CNA stated she forgot to change gloves and perform hand hygiene because she was nervous.

The facility also failed to implement EBP for a male resident with dementia, anemia, hypertension, emphysema, and a surgical wound to the back. His care plan and active orders documented that he had a surgical site and required wound care with non-surgical dressings, and that he was on EBP with gloves and gown to be applied when wound care was performed. However, observation of his room showed no EBP signage on the door and no PPE available near the room, despite wound care having been provided the day before the survey. The facility’s infection control policy and EBP in-service materials required that hand hygiene be performed before and after direct resident contact, after removing gloves, and during personal care, and that EBP rooms have a sign posted outside the room indicating when to wear gowns and gloves, with gowns and gloves available outside the room. In interviews, the DON and ADON confirmed that the resident was supposed to be on EBP, that his room should have been marked with a sign, and that PPE should be available, but the DON stated she did not know what happened to the sign or the PPE box that had been outside the door.