Infection Control Lapses in EBP and Device Handling
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with active medical devices, including a central line, which is a requirement under the facility's infection prevention and control program. The resident, who was at risk for skin integrity issues, had active orders for treatments but no EBP orders were found upon record review. Observations revealed that there was no EBP sign or Personal Protective Equipment (PPE) at the resident's doorway, and staff were not wearing gowns during direct care. The Infection Preventionist acknowledged the oversight, admitting it was an error and that the resident should have been on EBP. Additionally, the facility failed to maintain proper infection control practices for another resident with a drainage bag. The resident's drainage bag was observed resting on the floor, which contradicts the Centers for Disease Control and Prevention's recommendations. The Preventionist was unaware of the policy regarding the placement of the drainage bag and did not provide a policy to justify the practice. The Assistant Director of Nursing (ADON) acknowledged the issue but noted the difficulty in keeping the bag off the ground due to the bed's position. These deficiencies highlight lapses in the facility's infection prevention and control measures, particularly in the implementation of EBP and the handling of medical devices. The lack of adherence to established protocols and the absence of clear policies contributed to the deficiencies observed by the surveyors.
Plan Of Correction
1. Resident's #1 orders for EBP (Enhanced Barrier Precautions) were immediately ordered and implemented. On supplies and signage were placed on door, and the bin for gowns was placed in the resident's room. 2. Resident's #3 bag was immediately changed. An audit was conducted by IPCO, of all residents with and to ensure they had orders for EBP (Enhanced Barrier Precautions). No others were identified. On an audit of all residents with was conducted by IPCO to ensure that no other residents with were on the floor. No others were identified. On the IPCO, ADON and nurse received one on one re-education by RCD regarding EBP for residents with and as outlined by the CDC. By nursing staff will be re-educated by DON/ADON/Designee on EBP for residents requiring it as outlined by the CDC. 3. Random audits to be conducted by DON or Designee 4 X a week for 4 weeks, then 2 times a week for 4 weeks, then weekly for 4 weeks, to ensure residents with and have orders for EBP (Enhanced Barrier Precautions) as outlined by the CDC. Random audits to be conducted by DON or Designee 4 X a week for 4 weeks, then 2 times a week for 4 weeks, then weekly for 4 weeks to ensure that residents with an that their bag is not touching the floor. 4. The QA & A/QAPI committee will review the results of the audits in the monthly QA & A Meeting for 3 months and as deemed necessary and make recommendations based on outcomes. QA & A/QAPI Committee will determine the need for further auditing beyond 3 months.