Failure to Follow Enhanced Barrier Precautions and Infection Control Protocols
Penalty
Summary
The facility failed to adhere to enhanced barrier precautions for two residents, identified as R13 and R68, which is a critical component of infection prevention and control. Resident R13, who had a diagnosis of heart failure, hypertension, and diabetes, was ordered to be under Enhanced Barrier Precautions (EBP). However, during a medication administration, the registered nurse (RN) did not utilize a gown as required by the EBP signage on the door. Similarly, Resident R68, who had anemia, hypertension, and diabetes, was also under EBP due to wounds. During a dressing change, the RN failed to use a gown and did not establish a clean field, leading to potential cross-contamination. The dressing change for Resident R68 was not conducted according to the facility's policy. The RN placed dressing supplies directly on the bed, used a washcloth provided by the resident as a barrier, and did not follow proper hand hygiene protocols. The RN also used undated, opened treatment supplies from the bedside stand and dispensed Medi honey directly from the tube onto the wound, which is against the facility's guidelines. These actions demonstrate a lack of adherence to infection control procedures, increasing the risk of infection spread. Additionally, the facility's infection control program was found lacking in its surveillance system. In January 2025, 27 residents had gastrointestinal complaints, but the facility's infection control tracking did not include these cases in their mapping. The Infection Preventionist confirmed that residents diagnosed with norovirus were not included in the infection control mapping, and there was no tracking of COVID-19 symptoms among residents or staff. This indicates a failure in the facility's system to track, trend, and map infections, which is essential for identifying and controlling potential outbreaks.
Plan Of Correction
1. Residents and staff had no negative effects related to Enhanced Barrier Precautions and Infection Control surveillance. 2. DON/designee to educate Infection Control nurse and licensed staff on Enhanced Barrier Precautions, cross contamination during dressing changes, and surveillance tracking. 3. DON/designee to educate all staff on Enhanced Barrier Precautions and Infection Control and Prevention surveillance. 4. DON/designee to audit Enhanced Barrier Precautions and what residents require EBP, EB[R]P observations on use of proper precautions/attire, dressing changes observations to ensure no cross-contamination and review of infection control surveillance for thoroughness 1x/week for 4 weeks, then monthly x 2 months. 5. Results to be submitted to QAPI for review and approval.