Failure to Maintain Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain enhanced barrier precautions for Resident R15, as required by infection prevention and control regulations. Resident R15, who was admitted with multiple diagnoses including Parkinson's disease, dyskinesia, anxiety, bipolar disorder, muscle wasting, and dysphasia, required enteral nutrition through a gastrostomy tube. The care plan for Resident R15 included goals to keep the tube insertion site free of infection and interventions to monitor and report any signs of aspiration or fever. Despite these precautions, an observation on December 18, 2024, revealed that a nurse aide, Employee E6, was providing incontinence care to Resident R15 while only wearing gloves and not a gown, as mandated by the enhanced barrier precautions. The enhanced barrier precautions, as outlined by the CDC, require the use of gowns and gloves during high-contact resident care activities to prevent the spread of multi-drug resistant organisms. A sign posted outside Resident R15's room clearly indicated the need for such precautions during activities like dressing, bathing, transferring, and providing hygiene. However, during the observation, Employee E6 confirmed awareness of the enhanced barrier precautions but failed to adhere to the proper procedure by not wearing a gown. This lapse in following the infection control protocol contributed to the facility's failure to meet the infection prevention and control requirements.
Plan Of Correction
1. On 12/18/24 the Nurse Manager assessed resident R15 and there were no negative outcomes. The CNA, Employee E6 was immediately educated by the DON on 12/18/24. 2. On 12/18/24 the managers assessed all residents with Enhanced Barrier Precautions to verify that proper PPE was available. 3. The NHA started education for all staff on 12/26/2024 on infection control and prevention. The DON/designee will educate the remainder of the staff by 1/16/2025. 4. The DON/designee will conduct audits on Enhanced Barrier Precautions 3x a week for 4 weeks and monthly for 3 months.