F0880

D

Failure to Follow Hand Hygiene, PPE, and EBP Protocols During High-Contact Care

Sandstone, Minnesota Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its own infection prevention and control practices, including hand hygiene, glove use, surface disinfection, and Enhanced Barrier Precautions (EBPs), for three residents on EBPs during high-contact care. For one resident with multiple pressure injuries and a Foley catheter, the DON repeatedly failed to perform hand hygiene between glove changes and between care of different wounds. During wound care to the left foot, the DON removed soiled dressings, discarded gloves, and applied new gloves without hand hygiene, then cleansed and dressed a stage II heel wound and a stage III lateral foot wound without changing gloves or performing hand hygiene between steps until later in the procedure. The DON also attempted Foley catheter insertion multiple times, changing to sterile gloves and opening new catheter kits without performing hand hygiene between attempts. When providing care to the resident’s stage IV coccyx and left gluteal fold wounds, the DON removed dressings without changing gloves and performing hand hygiene, handled paper tape measures between the wounds and the bedside table without hand hygiene, and did not change gloves or perform hand hygiene between cleansing the two separate wounds.

The same resident’s care involved additional infection control lapses related to contaminated items and environmental surfaces. The DON placed used paper tape measures on the bedside table and on top of an open box of facial tissues, then later on the flap of an open box of ostomy bags, after the tape measures had been in contact with the resident’s wounds and the bedside table. The nurses did not disinfect the over-bed table where the soiled tape measures had been placed before exiting the room. This resident’s quarterly MDS documented diagnoses including Type 2 diabetes mellitus, paraplegia, encephalopathy, and multiple pressure ulcers (two stage III, one stage IV, and one deep tissue injury). The resident’s care plan indicated she was on EBPs per CDC recommendations for wounds, with a goal to remain free of multidrug-resistant organisms (MDRO), and that she was cognitively intact but dependent on staff for all care and mobility.

For a second resident on EBPs with a stage IV pressure ulcer and severely impaired cognition, staff failed to implement required gown use during high-contact care. An EBP sign and PPE cart were present outside the room, but an NA entered wearing only gloves and a mask while an RN, an agency nurse, entered with a mask, gloves, and gown and did not instruct the NA to don a gown. The NA assisted with positioning the resident for coccyx wound care, with her scrubs in contact with the resident’s bedding and handrail, and had been providing care for this resident for weeks without using a gown. The NA reported she did not see the EBP sign, did not know the PPE cart was intended for that resident, and had not been shown how to access residents’ care plans, while the ADON later acknowledged EBPs had been missed on this resident’s care plan.

For a third resident on EBPs with stage III coccyx and stage IV left gluteal wounds, the DON again failed to follow infection control practices during wound care. The DON used a paper measuring tape on the coccyx wound, wrote measurements on it, and placed the tape directly on the bedside table where red liquid was observed on the back of the tape, and it touched the resident’s water mug. The DON changed gloves but did not perform hand hygiene before measuring the left gluteal wound with a new paper tape measure. At the end of the procedure, the DON picked up the marker and soiled tape measures with bare hands, placed them in her scrub pocket, and later placed them on the treatment cart next to a laptop in the hallway. The nurses did not disinfect the bedside table after wound care. Facility policies on hand hygiene, PPE, and EBPs required hand hygiene before and after glove use, between contaminated and clean body sites, after handling used dressings or contaminated equipment, and after glove removal, and directed that gloves do not replace handwashing and that gowns and gloves be used for high-contact care for residents with wounds or indwelling devices under EBPs.