Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to enhanced barrier precautions (EBP) for a resident identified as having a multi-drug-resistant organism (MDRO), wounds, and indwelling medical devices. The facility's policy required staff to wear gowns and gloves when providing high-contact care to residents under EBP. However, during observations, staff members were found not wearing gowns while providing direct personal hygiene and wound care to the resident. This non-compliance was confirmed through staff interviews, where both a nurse aide and a wound care registered nurse admitted to not wearing the required protective gowns. The resident involved had a complex medical history, including a neurogenic bladder, paraplegia, and depression, and was admitted with a suprapubic catheter, colostomy, and wound, necessitating the use of EBP. Despite the presence of EBP signage on the resident's door and specific physician orders and care plans indicating the need for EBP, staff failed to comply with these precautions. The Director of Nursing confirmed the facility's failure to follow the required EBP for this resident.
Plan Of Correction
1. Root cause analysis will be conducted with facility infection control committee to determine barriers to compliance with enhanced barrier precautions. 2. Infection preventionist completed the Nursing Home Infection Preventionist Training Course through the CDC. 3. Facility contracted with Core Tactics to conduct on-site in-servicing for infection control on 3/11/25-3/12/2025. Education will include policy and procedure for enhanced barrier precautions. Director of nursing or designee will educate nursing staff facility on enhanced barrier precaution policy and procedure. 4. Director of nursing or designee will audit 5 staff members daily for 30 days to ensure proper PPE use, handling of soiled linen, sharps and biohazardous material, and handwashing. Audits will occur twice weekly thereafter for an additional 30 days. Audit findings will be shared with QAPI committee.