Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection control program related to Enhanced Barrier Precautions for three residents with sacral wounds. The facility's policy on Enhanced Barrier Precautions, dated March 6, 2024, requires the use of gowns and gloves during high-contact resident care activities to prevent the transmission of multidrug-resistant organisms. However, observations revealed that staff members only wore gloves while providing wound care to residents with sacral wounds, failing to adhere to the policy's requirement for gown use. Resident R1 had a stage IV pressure ulcer on the sacrum, and a care plan for Enhanced Barrier Precautions was initiated in April 2024. During an observation, a licensed nurse and a unit manager provided wound care to Resident R1 without wearing gowns, only using gloves. Similarly, Resident R2, who also had a pressure wound, was observed receiving wound care from staff who did not wear gowns, despite the care plan initiated in March 2025 for Enhanced Barrier Precautions. Resident R3, with a stage IV pressure ulcer, was also observed being repositioned by staff who only wore gloves. Additionally, there was no signage posted on the doors or walls of the rooms of Residents R1, R2, and R3 to indicate the need for Enhanced Barrier Precautions. The unit manager confirmed the lack of adherence to Enhanced Barrier Precautions and the absence of appropriate signage.
Plan Of Correction
Residents R1, R2 and R3 were not at risk and not harmed. An audit was completed to ensure enhanced barrier precautions were in place. No other additional findings noted. Employees were educated on enhanced barrier precautions. The facility purchased the additional equipment needed for isolation precautions. NHA, DON and/or Designee will conduct weekly audits on isolation precautions for 4 weeks to ensure enhanced barrier precautions protocol is complete, then monthly for 3 months to ensure compliance. Results of monthly audits will be reported to the QA Steering committee by the NHA/DON and/or Designee for 3 months to the QA Steering committee for action. Following the 3 months, the committee will determine the frequency and need of additional audits moving forward.