Failure to Follow Hand Hygiene, Glove Use, and EBP PPE Requirements During Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policies regarding hand hygiene, glove use, and use of PPE, including Enhanced Barrier Precautions (EBP), for multiple residents. A nurse administering medications to one resident handled capsule medications with bare hands after touching various objects and surfaces, without performing hand hygiene, and then opened the capsules and mixed their contents into applesauce for the resident to ingest. Another nurse later stated that staff are supposed to sanitize their hands before opening capsules and avoid touching anything prior to handling medications to prevent contamination. For a resident on EBP due to a leg wound requiring wound care, two CNAs provided incontinence care after the resident had a bowel movement and was wet with urine. They wore gloves but did not don complete PPE as required for residents on EBP. One CNA used double gloves to clean the perineal area, then removed only the outer gloves and, with the remaining gloves still on, applied barrier cream and a new incontinence brief. After removing the second pair of gloves, the CNA assisted the resident to dress without performing hand hygiene. The DON later stated that staff must wear complete PPE when providing direct care to residents on EBP to prevent potential spread of infection or cross contamination. Additional deficiencies were observed during incontinence and toileting care for other residents. One CNA assisted a resident to the toilet, cleaned the perineum, removed a soiled brief, applied a clean brief, pulled up the resident’s pants, and assisted the resident back to a wheelchair while wearing the same soiled gloves and without hand hygiene between dirty and clean tasks. The same CNA, when providing incontinence care to another resident, cleaned the perineum, applied a new brief, repositioned the resident, and straightened bed linens while wearing the same soiled gloves, then removed PPE and left the room without hand hygiene. Another CNA, assisted by a second CNA, cleaned a resident’s anal and perineal areas while wearing gloves, then, using the same soiled gloves, applied a clean brief, pulled up the resident’s pants, and touched the bed control. This CNA later acknowledged not removing the soiled gloves or performing hand hygiene before proceeding to clean tasks, contrary to the facility’s hand hygiene and PPE policies, which require glove removal and hand hygiene after contaminated tasks and before moving to clean tasks.
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