Failure to Follow Hand Hygiene, PPE, and Enhanced Barrier Precautions During Care
Penalty
Summary
The deficiency involves failures in hand hygiene and glove use during medication administration and blood glucose monitoring, as well as failures to implement enhanced barrier precautions and appropriate personal protective equipment during wound care. On February 24, 2026, a registered nurse prepared and administered Atropine 1% eye drops to the right eye of a resident (R10), then, while still wearing the same clean gloves, removed the resident’s sweater, placed it on the wheelchair, and handled puzzle papers and other bedside items. Without removing the gloves, performing hand hygiene, and donning a new pair of gloves, the nurse then opened and administered Prednisolone 1% eye drops to the same eye and dabbed under the eye and face with a tissue. The DON later stated that the nurse should have removed the dirty gloves, performed hand hygiene with alcohol rub/sanitizer, and applied new gloves before administering the second eye drop to prevent contamination, as required by the facility’s hand hygiene and glove-use policies. On February 23, 2026, an LPN prepared to check another resident’s (R68) blood sugar level while standing outside the resident’s room. The LPN donned gloves and, while wearing them, touched and opened the medication cart to obtain a lancet, locked the cart, and turned off/closed the computer attached to the cart. The LPN then entered the resident’s room and, using the same gloves, cleansed the resident’s left middle finger with an alcohol pad and performed the fingerstick to obtain blood for glucose monitoring. The DON later stated that the LPN should have removed the gloves used to handle the cart and computer, performed hand hygiene with alcohol rub/sanitizer, and then applied new gloves before performing the blood sugar monitoring procedure, in accordance with the facility’s policies that require hand hygiene immediately after glove removal and emphasize that glove use does not replace hand hygiene. A third resident (R88) had multiple diagnoses including Alzheimer’s disease, anxiety disorder, dysphagia, muscle weakness, a stage 3 pressure ulcer of the sacral region, and abnormal weight loss. Documentation showed a new unstageable coccyx pressure wound identified on December 8, 2025, later described as a stage 3 coccyx pressure injury. As of February 24, 2026, there was no physician order or care plan for enhanced barrier precautions (EBP) for this resident. Observations on February 23 and 24, 2026 showed there was no EBP signage on or around the resident’s room door and no personal protective equipment outside the room, despite the infection preventionist later stating that residents with chronic wounds or pressure ulcers should be on EBP. During coccyx wound care on February 24, 2026, a wound care advanced practice nurse entered the room and measured/assessed the open coccyx wound, approximately 2 centimeters in diameter, without donning a gown and while wearing a lab coat, leaning an arm on the resident’s bed, contrary to the facility’s EBP policy that requires PPE for high-contact resident care activities including wound care for residents with wounds requiring dressings.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.