Failure to Follow Hand Hygiene and PPE Protocols During Wound and Catheter Care
Penalty
Summary
The deficiency involves failures in infection prevention and control practices, specifically improper hand hygiene, glove use, and PPE use during care of residents on Enhanced Barrier Precautions. Facility policies require changing gloves and performing hand hygiene between clean and dirty tasks, when moving from one body part to another, and during wound care after removing soiled dressings and after cleansing the wound. Policies also require gowns to be fastened in the back and wound care to be performed in a manner that decreases potential for infection and cross-contamination. For one resident with severe cognitive impairment, morbid obesity, type 2 diabetes with hyperglycemia, and an unstageable sacral pressure ulcer, nurses performed sacral wound treatment while on Enhanced Barrier Precautions. The RN entered the room wearing gown, gloves, and mask, used her gloved hands to move the bed, and then proceeded directly to wound cleansing without changing gloves. Another RN, also wearing her initial pair of gloves, handled clean gauze, applied saline, and prepared a cotton swab with Santyl, handing these items to the first RN, who continued to use the same gloves throughout the procedure. The clean abdominal dressing was also handled and applied while both nurses continued to wear their original gloves placed upon room entry, without any glove change or hand hygiene between dirty and clean steps of the wound care. For another resident on Enhanced Barrier Precautions due to an indwelling urinary catheter, two CNAs performed catheter and incontinence care without adhering to PPE and hand hygiene standards. One CNA’s gown was not tied while providing care. After cleaning stool from the catheter with washcloths, the CNA used the same contaminated gloves to wet new washcloths in a pan of water, then emptied the stool-contaminated water into the resident’s bathroom sink, removed gloves, and donned new gloves without hand hygiene. The CNA then cleansed the resident’s bottom, removed a soiled brief, and again changed gloves without hand hygiene. The second CNA emptied urine from the catheter bag into a plastic container, placed the container on the bedside table, and then emptied it into the bathroom sink. Both CNAs removed PPE and exited the room without performing hand hygiene, and the bedside table and bathroom sink were not disinfected after being used for contaminated materials.
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