Failure to Follow Enhanced Barrier Precautions and Equipment Sanitization
Penalty
Summary
The facility failed to follow its own Enhanced Barrier Precautions (EBP) policy and procedures for residents with chronic wounds or indwelling medical devices, as well as failed to sanitize shared equipment between resident use. For one resident with a coccyx wound, the care plan did not document the need for EBP, and there was no EBP sign posted on the door. Staff, including an LPN and the Infection Control Preventionist, performed wound care without wearing gowns, despite the wound exhibiting significant drainage. The Infection Control Preventionist stated that full PPE was not required unless the wound was chronic, repeat, or infected, which was inconsistent with the facility's policy. Another resident with multiple comorbidities, including peripheral vascular disease and chronic kidney disease, had significant lower leg edema and weeping wounds. Although an EBP sign was posted on the door, staff entered the room and performed wound care without donning protective gowns. The wound nurse and DON provided conflicting statements about when EBP should be implemented and what PPE was required, indicating a lack of consistent understanding and application of the policy among staff. Additionally, staff failed to sanitize a mechanical lift and slings between use for two residents during toileting and personal care. The same lift and slings were used for both residents without cleaning or sanitizing in between, despite the facility's policy requiring equipment used by more than one resident to be cleaned and sanitized between each use. The administrator confirmed that equipment should be sanitized between uses, but this was not done in these observed instances.