Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, including Enhanced Barrier Precautions (EBP) and hand hygiene, during resident care. Surveyors observed two CNAs providing perineal care to a resident when one CNA used the same soiled gloved hand that had been used for peri-care to open a drawer, remove barrier cream, and apply it to the resident’s buttocks. The same CNA then removed her gloves and applied a new pair without performing hand hygiene. The second CNA did not change gloves after cleansing a small, soft bowel movement and continued assisting the resident with clothing, then removed her soiled gloves, did not perform hand hygiene, touched the doorknob, exited and re-entered the room, and applied new gloves. In interviews, both CNAs stated they did not realize they were required to wash their hands after removing soiled gloves and did not realize they had used soiled gloved hands to open drawers and apply barrier cream. In a separate observation, one of the same CNAs provided ostomy care to another resident by removing the ileostomy bag and wafer, cleansing around the stoma, and then using the same soiled gloves to open a box of ostomy supplies, remove a new bag/wafer, and apply it to the resident’s abdomen. The CNA then opened a drawer with gloved hands to obtain wipes and barrier cream, applied new gloves, opened the bathroom and closet doors, removed a brief, cleansed the resident’s buttocks, and applied barrier cream. Afterward, the CNA removed her gloves and assisted the resident with her brief without performing hand hygiene. The assisting CNA also removed her gloves, failed to perform hand hygiene, applied new gloves, and opened the closet door to remove the resident’s clothes. In interviews, both CNAs acknowledged they did not realize they had to wash their hands when removing gloves during care and that they had used soiled gloved hands to open drawers and closets and to handle supplies. Additional deficiencies were observed during wound care for another resident and during wound care for a resident on EBP. A wound care consultant removed soiled dressings from a resident’s right foot and great toe, removed her gloves, and then applied new gloves without hand hygiene. Another consultant cleansed the open wound using a 4x4 gauze without flipping it, kept the same gloves on, and then handled clean dressings, the treatment cart, and door handles with those gloves. The primary consultant intermittently removed one glove to use her phone for wound measurements and photographs, reapplied gloves without hand hygiene, and continued wound care. The second consultant continued to wear the same gloves used to clean the wound while opening drawers on the treatment cart, entering the resident’s closet to obtain dressings, and wiping down the treatment cart. In a separate observation, multiple wound care consultants provided wound care to a resident on EBP who had a Foley catheter, colostomy, and hemodialysis port, but none wore gowns as required; all wore gloves only. Interviews with the wound care consultants and the facility’s infection preventionist confirmed that gowns and gloves were required for residents on EBP and that staff were expected to perform hand hygiene after glove removal and avoid touching clean items or residents with soiled gloves, consistent with the facility’s EBP and hand hygiene policies.
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