Inadequate Infection Control Practices for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to acceptable infection control practices concerning enhanced barrier precautions (EBP) during the care of a resident with a sacral wound and a foley catheter. Specifically, during a wound dressing change for Resident R78, both the Registered Nurse (RN) and the Nursing Assistant (NA) did not wear the appropriate personal protective equipment (PPE), such as gowns, which is required under EBP. This lapse was confirmed by RN Employee E1 during an interview, acknowledging that a gown should have been worn during the procedure. Additionally, the facility did not have any signage or PPE available outside Resident R78's room to alert or equip staff and visitors regarding EBP. The Director of Nursing (DON) confirmed that the facility had several residents with medical devices such as foley catheters, feeding tubes, colostomies, wounds, and dialysis catheters, yet EBP was not maintained for these residents. The DON acknowledged that staff should have been wearing gloves and gowns when providing care to these residents, indicating a systemic issue in the facility's infection control practices.
Plan Of Correction
Policy on Enhanced Barrier Precautions was added to the Facility Infection Control Policies. All residents of the facility who require Enhanced Barrier Precautions were ordered enhanced barrier precautions by their physician. Appropriate signage was placed on the doors of the residents who were ordered enhanced barrier precautions and appropriate PPE was made available. A letter was mailed out to each resident's responsible person concerning enhanced barrier precautions. Nursing was in-serviced by the Director of Nursing on 12/19/2024 on Enhanced Barrier Precautions. Infection preventionist or nurse designee will monitor residents on Enhanced Barrier to ensure that the appropriate signage and PPE is provided and that staff are donning, doffing and utilizing the appropriate PPE as needed when caring for these residents. Monitoring will occur at least once a week on all 3 shifts weekly for 4 weeks and then at least monthly until deemed in compliance by facility QAPI Committee.