Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control guidelines as outlined by the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) for a resident identified as Resident 79. The deficiency was observed when a nurse aide did not follow the Enhanced Barrier Precautions (EBP) while providing care to the resident. Specifically, the nurse aide was observed emptying the resident's indwelling catheter drainage bag without wearing a gown, which is a requirement under the EBP for high-contact care activities. Resident 79 had an indwelling catheter and a diagnosis of quadriplegia, which placed them at high risk for acquiring or spreading multidrug-resistant organisms (MDROs). The facility's policy, in line with CDC guidelines, required the use of gown and gloves during high-contact care activities for residents with indwelling medical devices. Despite signage on the resident's door indicating the need for EBP, the nurse aide only wore gloves and failed to don a gown while performing the task. The Licensed Practical Nurse/Infection Control Preventionist confirmed that the nurse aide should have been wearing both a gown and gloves while emptying the catheter drainage bag and assisting the resident to reposition in bed. This oversight in following the established infection control protocols contributed to the facility's failure to prevent the potential spread of infections, as required by the infection prevention and control program.
Plan Of Correction
Preparation and submission of this Plan Of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #79 did not have any adverse reactions. There were no other issues identified at the time of the survey. To prevent a future occurrence, the Director of Nursing/designee will educate nursing staff on the proper use of personal protective equipment and when to use it. To monitor and maintain ongoing compliance, the director of nursing/designee will complete an audit weekly x4 and then monthly x2 to ensure staff is wearing the proper personal protective equipment. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.