Failure to Follow Hand Hygiene and Enhanced Barrier Precautions During Colostomy Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain proper infection prevention and control practices during colostomy care for one resident. The resident was an adult male with a history of sepsis, septicemia, perforation of the intestine, colostomy status, and malignant neoplasm of the rectum. His MDS showed intact cognition with a BIMS score of 13, and his care plan noted an ostomy secondary to bowel perforation with colostomy care ordered every shift as needed and monitoring for signs of infection. Physician orders reflected that the resident was to be on enhanced barrier precautions related to his colostomy and drain, and an enhanced barrier precaution sign and PPE supplies were present outside his room. On the observed date and time, RN C was at the medication cart preparing a colostomy bag for this resident. While preparing, she touched scissors and the left side of her shirt, both of which the DON later identified as contaminated items. Without performing hand hygiene after these contacts, RN C then touched the wafer of the colostomy appliance. She proceeded to walk down the hall to the resident’s room without sanitizing her hands. Upon entering the resident’s room, which was posted for enhanced barrier precautions, RN C did not don a gown and only applied gloves after entry, again without washing or sanitizing her hands. While donning the gloves, she touched the outside (fourchettes) of the gloves with her contaminated fingers and hands, and then proceeded to change the colostomy and apply a new colostomy bag. In subsequent interviews, RN C acknowledged she had not sanitized her hands after using the scissors and touching her shirt, confirmed she was expected to perform hand hygiene before donning gloves, and agreed that the gloves were contaminated by her technique. She also admitted she had no reason for not wearing a gown despite the enhanced barrier precaution signage and available PPE, and the DON confirmed that this conduct did not follow facility infection control protocols.
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