Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions for four residents, leading to a deficiency in infection prevention and control. The facility's policy on enhanced barrier precautions, which was reviewed in July 2024, mandates the use of personal protective equipment (PPE) such as gowns and gloves during high-contact resident care activities for residents with wounds or indwelling medical devices. However, observations and interviews revealed that these precautions were not followed for residents with indwelling catheters and pressure ulcers. Resident R36, who had an indwelling catheter, and Resident R50, who had pressure ulcers, did not have enhanced barrier precautions documented in their care plans. Observations showed no signage indicating the need for such precautions on their doors, and no gowns or waste containers were available outside their rooms. Interviews with the residents and staff confirmed the lack of awareness and implementation of these precautions. Similarly, Residents R24 and R48, both with indwelling catheters, also lacked signage and available gowns outside their rooms. Interviews with the residents and staff further confirmed the absence of enhanced barrier precautions. The Unit Manager acknowledged the lack of signage and gowns, indicating a systemic failure to adhere to the facility's infection control policies.
Plan Of Correction
1- Residents R36, R50, R24, and R48 were all placed on Enhanced Barrier Precautions. This includes PPE immediately available outside of the resident's room and a waste container near the exit of the room with signage posted for each resident's room. All residents will be screened during the admissions process for the need of Enhanced Barrier Precautions prior to admission to the facility. The Director of Nursing/Designee will review the new orders report to determine if Enhanced Barrier Precautions need to be initiated and added to a resident's plan of care. All licensed staff will be educated on the policy and procedures of Enhanced Barrier Precautions and the location of where PPE will be readily available on the nursing units. The Director of Nursing/Designee will perform random weekly audits times 4, then monthly audits times 4, then quarterly audits times 4 to assure the facility has implemented Enhanced Barrier Precautions for the required residents. Audit results will be reported by the Director of Nursing/Designee through the Quality Assurance meeting and/or the Facilities Governing Body meetings for compliance. Date of Corrective action: May 30, 2025.