Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its own infection control practices regarding Enhanced Barrier Precautions (EBP) for residents in two units. The facility's policy, dated September 2024, specifies that EBP are necessary to prevent the transmission of multi-drug resistant organisms (MDROs) through contaminated hands and clothing of healthcare workers. These precautions are particularly important for residents with chronic wounds, indwelling devices, or those colonized or infected with MDROs. However, observations revealed that a Certified Registered Nurse Practitioner (CRNP) did not don a gown while performing a wound assessment on a resident with a chronic stage four coccyx pressure ulcer and a foley catheter, who was under EBP. Additionally, it was observed that there was no Personal Protective Equipment (PPE) available at the doorways or in the hallways for several rooms housing residents requiring EBP. Interviews with staff, including a Nursing Assistant and the Director of Nursing, confirmed the absence of readily available PPE and acknowledged that staff should have been wearing appropriate PPE, such as gloves and gowns, when providing care to these residents. This lack of adherence to the facility's infection control policy was confirmed by the Director of Nursing.
Plan Of Correction
Resident 42 no longer resides in the facility. b. Director of nursing/designee completed a whole house audit to verify any resident requiring enhanced barrier precautions has personal protective equipment readily available outside of room. c. Nursing home administrator/designee educated all facility staff and wound nurse practitioner on personal protective equipment, enhanced barrier precautions and F880. d. Nursing home administrator/designee will audit personal protective equipment availability and use for 3 enhanced barrier precautions residents per floor daily x 5 days; weekly x 3 weeks; monthly x 2 months. e. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.