Failure to Adhere to Enhanced Barrier Precautions for Resident with ESBL
Penalty
Summary
The facility failed to maintain an effective infection control program related to Transmission Based Precautions for one resident, identified as Resident R49. The facility's policy on Enhanced Barrier Precautions, revised in December 2024, outlines the use of targeted personal protective equipment (PPE) to reduce the transmission of Multi-Drug Resistant Organisms (MDROs), including ESBL-producing Enterobacterales. Resident R49 was listed under Enhanced Barrier Precautions due to an ESBL infection, and a physician order dated April 17, 2024, confirmed the need for infection precautions. On December 15, 2024, an observation revealed that a Nurse Aide, identified as Employee E16, was providing cleaning care to Resident R49 without wearing the required PPE, despite the resident being on Enhanced Barrier Precautions. The lack of PPE use was confirmed with Employee E16 at the time of the observation. This failure to adhere to the facility's infection control policy represents a deficiency in maintaining an effective infection prevention and control program.
Plan Of Correction
NPE / DON / Designee will re-educate nursing staff on appropriate PPE based on identified Enhanced Barrier Precautions. Infection Prevention Nurse / Designee to complete weekly audits X 4 then monthly X 2 on 5 random residents on Enhanced Barrier Precautions to ensure staff are utilizing appropriate PPE. DON / Designee will report the findings of the audits to the QAPI Committee X 3 months. Resident R49 remains on Enhanced Barrier Precautions with staff utilizing appropriate PPE with provision of direct care. Infection Prevention Nurse / Designee to complete an initial audit of residents on Enhanced Barrier Precautions to ensure nursing staff utilizing appropriate PPE.