Inadequate Infection Control Practices for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure a safe, sanitary, and comfortable environment to prevent the transmission of communicable diseases and infections for a resident on enhanced barrier precautions. The resident, who had a history of cerebral infarction and diabetes, required significant assistance for personal hygiene and was at risk for infections due to pressure ulcers and urinary tract infections. Despite these precautions, staff did not adhere to the required use of personal protective equipment (PPE) such as gowns during high-contact care activities. During an observation, two Certified Nurse Aides (CNAs) were seen providing care to the resident without wearing gowns, despite the presence of a sign indicating the need for enhanced barrier precautions. The CNAs engaged in activities such as emptying a urine drainage bag and providing incontinence care without the appropriate PPE. Additionally, soiled linens were improperly handled, being placed directly on the floor instead of in a designated receptacle, which was not available in or near the resident's room. Interviews with the staff revealed a lack of awareness and adherence to the enhanced barrier precautions. One CNA admitted to forgetting to wear a gown, while another was unsure of the necessity of wearing one. A Licensed Practical Nurse (LPN) also failed to wear a gown during treatment, allowing their uniform to come into contact with the resident's bed linens. The Unit Manager and the facility's Infection Preventionist confirmed the requirement for PPE use during hands-on care for residents on enhanced barrier precautions, highlighting a gap in compliance and awareness among the staff.
Plan Of Correction
Plan of Correction: Approved February 2, 2025 The facility will continue to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by: Resident # 4 immediately received perineal care and clothing change. The resident was monitored for 5 consecutive days for any adverse effects. None noted. The resident’s care plan was reviewed and is in concert with the resident’s current needs and a medical record review completed with no abnormal findings. Environmental surfaces within the room were immediately disinfected and receptacles for soiled linen was placed inside the room and stocked cart of PPE supplies placed outside of the room. The Certified Nursing Assistants (#1 and #2) and Licensed Practical Nurse (#1) who provided care and handled linen was immediately counseled and re-educated regarding infection control practices including Enhanced Barrier Precautions (EBP) protocols, donning and doffing PPE, incontinent care, foley care, skin barrier application, linen handling, and handwashing procedures. Staff also received education on facility protocols for precaution signage to identify resident needs. Staff has been audited by the Clinical Instructor and successfully demonstrated understanding of procedures. No further concerns have been identified. The facility identified other areas that could potentially be affected by the deficient practice by: - All residents had the potential to be affected by the deficient practice. - The Clinical Instructor conducted 5 resident audits per unit verifying proper infection prevention and control practices. Audits also verified appropriate EBP setup was in place and accessible to staff. Any further issues were immediately rectified and staff counseled. Measures that will be put in place or systematic changes to ensure that the deficient practice will not recur: - The Clinical Instructor provided an educational program to all certified nursing assistants and licensed nurses regarding infection prevention and control and specifically related to EBP. Such education also included donning and doffing PPE, incontinent care, foley care, skin barrier application, linen handling, and handwashing procedures. - The Clinical Instructor/Designee will conduct weekly audits of (2) residents per unit to verify appropriate infection prevention and control standards. Audits will continue until 100% compliance is attained for 8 consecutive weeks. - The Environmental Services Manager will ensure rooms identified requiring EBP have the proper receptacles for donning and doffing PPE. Auditing of each EBP room setup will be conducted weekly. Audits will continue until 100% compliance is attained for 4 consecutive weeks. Results of the above will be provided to the Quality Improvement Committee on an ongoing basis to monitor compliance. The Director of Nursing will be responsible for monitoring compliance and follow up as necessary. If 100% compliance is not found, the staff involved will be counseled. The Quality Improvement Committee may make further recommendations including, but not limited to, ongoing education, additional audits, and/or process changes. Corrective action will be completed by (MONTH) 6, 2025. The Director of Nursing is responsible for the implementation of this plan with the Facility Administrator having overall responsibility for the conduct of the plan.