Inadequate Implementation of Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement an effective infection control program, specifically in the application of Enhanced Barrier Precautions (EBP) for residents with open wounds or indwelling medical devices. For one resident with an open wound following surgical amputation, there was no indication of EBP being ordered or monitored, and no signage or isolation cart was present in the resident's room. The Unit Manager and Director of Nursing confirmed that EBP should have been implemented upon the resident's return from the hospital. Another resident with a nephrostomy tube also lacked proper EBP signage, although an isolation cart was present inside the room. Additionally, a third resident with an indwelling catheter and pressure wound had EBP signage and an isolation cart, but the hand sanitizers located above the cart were empty, as observed by an LPN. The facility's policy on EBPs, which includes the use of gowns and gloves for high-contact activities and the posting of signage to indicate precautions, was not adequately followed, leading to potential cross-contamination and increased infection risk.
Plan Of Correction
Element 1: Resident 101 remains at this facility. Enhanced Barrier Precautions (EBP) were implemented 2/25/25 with PPE cart and signage outside her room; care plan and orders updated for EBP 2/25/25. Resident 103 discharged to her home on 3/7/25 after completing her rehab stay at this facility. EBP signage was placed outside her door on 2/25/25 above the PPE cart and remained in place until she discharged. Resident 102 remains at this facility. Hand sanitizers outside his room at the PPE cart were refilled on 2/25/25. Element 2: All residents currently in-house are at risk of requiring EBP that have not been implemented. An audit of all in-house resident orders will be completed to ensure EBP is properly in place. All residents currently on EBP are at risk of signage not being outside their door or hand sanitizer not being available. Rooms of all residents currently on EBP will be audited to ensure proper PPE cart, signage and hand sanitizer is available. Element 3: Infection Prevention Coordinator received Infection Prevention and Control Consultation education from the State Licensing Consultative Section (SLCS) on 2/27/25. All Licensed Nurses will receive education regarding Enhanced Barrier Precautions (EBP). Element 4: DON/Designee will audit 10 isolation carts per week for 4 weeks to check for hand sanitizer availability and proper isolation signage. DON/Designee will audit all new admission resident charts and 5 long term care resident charts per week for 4 weeks to check for EBP requirements in place. The DON is responsible for sustained compliance. Under the supervision of the QAPI committee, audits will be presented to the QAPI committee monthly and will continue until QAPI has determined sustained compliance has been achieved.