Failure to Maintain Hand Hygiene and Enhanced Barrier Precautions During Med Pass and Wound Care
Penalty
Summary
The deficiency involves failures in infection prevention and control practices during medication administration and wound care. During a morning medication pass, an LPN prepared and administered medications to two residents without performing hand hygiene upon entering their rooms, despite later stating that hand hygiene is performed before entering and exiting resident rooms. For one resident, the LPN prepared medications, poured water, locked the cart, entered the room, and handed the resident a medication cup and water without performing hand hygiene until exiting the room. For another resident, the LPN similarly prepared medications, entered the room, and administered medications with a spoon and applesauce without performing hand hygiene upon entry, only doing so upon exit. The DON later confirmed that staff should perform hand hygiene upon entering residents' rooms. The deficiency also includes improper infection control practices during wound care for a resident with multiple diagnoses, including palliative care encounter, congestive heart failure, acute kidney disease, chronic wounds, and a history of MDRO to the left heel. The resident’s care plan identified risk for MDRO and physician orders required Enhanced Barrier Precautions every shift, with posted signage directing hand sanitizing before entering and after leaving the room and use of gloves and gowns for high-contact care, including wound care. During observed wound care, an RN entered the room, performed hand hygiene, and applied gloves but did not wear a gown as required. The RN contaminated gloves by adjusting the bed with the same gloves used for wound care, placed the resident’s foot and wound-care supplies on the bed, used scissors taken from a pocket without sanitizing them, touched the bed footboard with gloved hands after donning clean gloves, and reapplied gloves at the end of the procedure without performing hand hygiene. The RN later confirmed that proper PPE, instrument sanitization, and hand hygiene should have been used.
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