Failure to Implement Enhanced Barrier Precautions and Proper Hand Hygiene
Penalty
Summary
The facility failed to implement and maintain proper infection prevention and control practices, specifically regarding enhanced barrier precautions (EBP) and hand hygiene, for several residents with indwelling medical devices or wounds. Multiple residents who required EBP due to the presence of devices such as indwelling catheters, gastrostomy tubes, or interventional radiology drains did not have appropriate EBP signage or personal protective equipment (PPE) carts outside their rooms as required by facility policy. In several cases, the residents' care plans or risk evaluation forms indicated the need for EBP, but there were no corresponding physician orders or visible precautions in place at the time of observation. Direct observations revealed that staff did not consistently follow proper glove use and hand hygiene protocols during resident care. For example, a CNA was observed providing incontinence care to a resident without changing gloves or performing hand hygiene between handling soiled and clean items, which is contrary to infection control standards. The Director of Nursing confirmed that hand hygiene and glove changes should occur after contact with dirty items and before touching clean items, but this was not observed in practice. Documentation reviews further showed inconsistencies between residents' medical records, care plans, and the actual implementation of EBP. Some residents with documented indwelling devices did not have EBP orders or visible precautions, while others had discrepancies between risk evaluation forms and progress notes regarding the presence of such devices. These lapses in infection control practices and documentation were observed for multiple residents, indicating a systemic failure to ensure adherence to established infection prevention protocols.