Failure to Implement Enhanced Barrier Precautions and Infection Control Practices
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for four residents, which is a critical infection control intervention aimed at reducing the transmission of multidrug-resistant organisms (MDROs). The residents involved had conditions such as surgical wounds, catheters, and recent surgeries, which increased their risk of MDRO acquisition. Despite these risks, the facility's policies did not include EBP, and there were no orders or care plans for EBP for these residents. Additionally, during a dressing change for one resident, the facility failed to adhere to proper infection control practices. The LPN involved did not perform hand hygiene after removing gloves and before donning new ones, which is a crucial step in preventing cross-contamination. This oversight occurred multiple times during the dressing change process, indicating a lapse in maintaining aseptic technique as outlined in the facility's wound care policy. Interviews with the Director of Nursing and the Infection Preventionist revealed a lack of awareness and implementation of EBP within the facility. The Director of Nursing acknowledged the absence of EBP in care plans, while the Infection Preventionist admitted to being unaware of the need for such precautions. This lack of knowledge and implementation contributed to the deficiencies observed during the survey.
Plan Of Correction
Residents R65, R115, R118 and R123 were discharged. At the time of the findings, all residents were assessed for the need to implement Enhanced Barrier Precautions (EBP) during high-contact resident care activities, and an EBP order and care plan was initiated as indicated. At the time of the findings, Employee E4 and all staff on duty were reminded to wash their hands after doffing soiled gloves and prior to donning a new pair of gloves during dressing changes to prevent cross-contamination. Facility policies HS-IC0609 and SRC-Infection Control-2.1 Transmission Based Precautions-A were reviewed and verified to include EBPs. All RNs, LPNs, and CNAs will be educated by the Administrator and/or designee to use EBPs during high-contact care activities for residents with: 1. Indwelling Medical Devices (such as but not limited to central line, urinary catheter, feeding tube, tracheostomy/ventilator), and when they should be implemented for residents. 2. Wounds 3. Colonization or Infection with a MDRO (Multi-Drug Resistant Organism). DON and/or designee will provide all RNs and LPNs education regarding the need to wash their hands after doffing soiled gloves and prior to donning a new pair of gloves during dressing changes to prevent cross-contamination. NHA and/or designee will audit/observe 4 residents per week to ensure EBPs are being implemented during high-contact resident care activities, and that there is an MD order and a care plan in place as indicated. Audits will be conducted weekly for 4 weeks, then monthly for 2 months or until substantial compliance is obtained. DON and/or designee will audit/observe 4 dressing changes per week to ensure RN and/or LPN providing care wash their hands after doffing soiled gloves and prior to donning a new pair of gloves during dressing changes to prevent cross-contamination. Audit will be completed weekly for 4 weeks, then monthly for 2 months or until substantial compliance is obtained. The results will be reviewed at the Quarterly QAA meetings.