Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to adhere to appropriate infection control practices by not wearing a gown during high-contact activities in a resident's room who was under Enhanced Barrier Precautions. This deficiency was identified for a resident reviewed for respiratory care. The resident's electronic medical record indicated an order for Enhanced Barrier Precautions every shift for catheter/wound care, requiring staff to wear a gown and gloves during high-contact activities such as dressing, bathing, transfers, linen changes, providing hygiene, brief changes, toileting assistance, indwelling medical device care, and wound care. During an observation, a Certified Nurse Aide (CNA) was seen providing incontinence care to the resident without wearing a gown, despite wearing gloves and a mask. The Unit Manager/Licensed Practical Nurse (UM/LPN) confirmed the CNA's failure to wear a gown during the care. The Infection Preventionist and the Director of Nursing (DON) both confirmed that staff are expected to wear a gown and gloves when providing incontinence care to residents under Enhanced Barrier Precautions. The facility's policy on Enhanced Barrier Precautions, dated March 2024, also outlined the requirement for gown and glove use during high-contact resident care activities to reduce the transmission of multiple-drug resistant organisms.
Plan Of Correction
Plan of Correction F880 Level E Completion Date: 1/15/2025 Corrective Action: 1:1 in-service provided to CNA #1 regarding appropriate PPE when providing care to a resident on Enhanced Barrier Precautions. ID Other Residents: Any resident within the facility who requires care. Systemic Change: In-service Enhanced Barrier Precautions and Proper PPE will be given facility to the Nursing Department by Infection Preventionist will be completed by 1/15/2025. Personal Protective Equipment (PPE) will be made available in clean work rooms as well as in each resident room who is identified on Enhanced Barrier Precautions (EBP). Monitoring: Audit - PPE for Enhanced Barrier Precautions will be completed on the following schedule: (4) weekly xos 2 weeks then (4) monthly xs 2 months then (4) quarterly x 1 quarter by Infection Preventionist. Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.