F0880

D

Failure to Perform Hand Hygiene Between Glove Changes and Adhere to Enhanced Barrier Precautions

Peoria Heights, Illinois Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves failures in the facility’s infection prevention and control practices, specifically related to hand hygiene between glove changes and adherence to Enhanced Barrier Precautions (EBP). For one resident with osteomyelitis, quadriplegia, dysphagia, pressure ulcers, neuromuscular bladder dysfunction, a suprapubic catheter, and a colostomy, the Infection Preventionist/Wound Nurse changed gloves multiple times during a wound care procedure but did not perform hand hygiene between glove changes, contrary to the facility’s Glove Use and Hand Hygiene policies that require hand hygiene after glove removal and before new glove placement. The Administrator later agreed that hand hygiene should have been conducted between glove changes.

The facility also failed to follow its EBP policy requiring gown and gloves for residents with indwelling medical devices during high-contact care. A resident with a feeding tube, care planned for EBP due to the tube, was observed receiving an enteral feeding disconnection and water flush from an RN who performed hand hygiene and donned gloves but did not wear a gown during the procedure; the RN acknowledged a gown should have been worn, and the Infection Preventionist confirmed that gown and gloves are required for any care involving a G-tube. In another instance, an RN performing a medication pass for a resident with cerebral palsy and type 2 diabetes, who required QID blood glucose checks and insulin, removed soiled gloves after performing a blood sugar check and then donned clean gloves at the medication cart without performing hand hygiene in between, despite facility policy and the DON’s confirmation that hand hygiene is required between glove changes.