Failure to Follow Hand Hygiene, PPE, and Nebulizer Storage Practices Under EBP
Penalty
Summary
The deficiency involves failures in infection prevention and control practices, including improper hand hygiene, PPE use, and storage of nebulizer equipment. Surveyors observed that two staff members entered a resident’s room on Enhanced Barrier Precautions (EBP) wearing gloves but without performing hand hygiene. During incontinence care, one staff member continued to pull up the resident’s pants while still wearing soiled gloves, then removed and reapplied gloves without hand hygiene. In separate observations, two residents’ nebulizer masks and equipment were found lying directly on bedside tables, one with residual fluid in the chamber, and not stored in sanitary containers between treatments, contrary to facility expectations. Additional observations showed a nurse performing dressing changes without adhering to EBP and infection control standards. For one resident with an enteral feeding site, the nurse used gloves taken from his pants pocket, did not don a gown for the dressing change, and placed a new syringe plunger into a soiled container without cleaning it. For another resident receiving wound care, the same nurse donned gloves from his pocket and a gown, left and re-entered the room multiple times without changing gloves or performing hand hygiene, assisted the roommate while wearing the same gloves, knelt on the floor, handled dressing supplies, cleansed and dressed the wound, and used a marker from his pocket to date the dressing, all without changing contaminated gloves. Facility leadership and the Infection Preventionist later confirmed that nebulizers should be bagged between treatments, PPE (including gowns) should be worn for dressing changes, gloves should be changed between soiled and clean tasks, and hand hygiene should be performed between glove changes, as required by the facility’s hand hygiene and EBP policies.
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