F0880

D

Failure to Follow PPE and Hand Hygiene Protocols During Wound Care and Peri-Care

Midlothian, Texas Survey Completed on 01-31-2026

Penalty

No penalty information released

Summary

The deficiency involves failures in the facility’s infection prevention and control practices for two residents during observed care. For one resident, a female with hemiplegia, hypotension, dementia, and a stage 4 pressure ulcer on the left heel, the care plan and orders documented that she was on enhanced barrier precautions for a suprapubic catheter and heel wound, and that wound care required daily dressing changes. During an observation of wound care, the LVN performed the procedure without donning a gown, despite the facility’s infection control policy requiring gown and gloves for high-contact resident care activities under enhanced barrier precautions. In an interview, the LVN acknowledged having been trained on evidence-based practice (EBP) protocols about a month earlier, stated that nurses were responsible for following the EBP policy, and admitted she forgot to wear a gown and understood that not following EBP could lead to cross contamination and passing infection to other residents.

For the second resident, a 78-year-old female with type 2 diabetes mellitus, repeated falls, neuropathic bladder, frequent urinary incontinence, and a history of recurrent UTIs treated with prophylactic antibiotics, staff were responsible per the care plan for checking for incontinence and washing, rinsing, and drying soiled areas. During an observation of peri-care, CNA A did not perform hand hygiene between glove changes while cleaning the resident’s front perineal area and before moving to the back (anal) area. After removing his gloves, CNA A touched the resident’s bedding and clothing while assisting with repositioning without sanitizing his hands. CNA B assisted by handing wipes during the peri-care.

In interviews, CNA A reported receiving in-service training on hand hygiene and peri-care about a month earlier but stated he was not aware of the need to sanitize hands between glove changes during peri-care and believed washing before and after the procedure was sufficient; he acknowledged that improper hand hygiene could cause cross contamination. CNA B stated she had received similar training a few months earlier and had been instructed to sanitize hands between glove changes during peri-care. The ADON, serving as Infection Preventionist, the DON, and the Administrator all stated that staff were trained to wear gowns and gloves for high-contact care under enhanced barrier precautions and to sanitize hands between glove changes during peri-care, and that they were responsible for monitoring staff compliance. Review of the facility’s peri-care and hand washing policy indicated it addressed hand cleansing to prevent transmission of infectious material but did not specify glove use or hand sanitizing between glove changes, while the infection control policy on enhanced barrier protection required gown and gloves during high-contact resident care activities for residents with wounds and indwelling devices.