Failure to Implement Infection Prevention and Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices during the provision of personal care and medical device management for several residents. Staff did not consistently use Enhanced Barrier Precautions (EBP), such as donning gowns and gloves, during high-contact care activities for residents with indwelling medical devices or open wounds. For example, one resident with a suprapubic catheter and a stage 2 pressure ulcer was observed receiving care without staff wearing the required gown or gloves, despite the resident being at increased risk for infection. The resident had declined EBP, and the facility honored this choice after providing education and obtaining a signed risk agreement. Another resident with severe cognitive impairment and an unhealed stage 3 pressure ulcer received a wound dressing change from an LPN who did not use EBP. Similarly, a resident with an indwelling catheter had their catheter bag emptied by a CNA without the use of EBP. A resident with a feeding tube also received tube feeding administration without staff donning the appropriate barrier precautions, even though staff acknowledged awareness of EBP requirements for residents with medical devices. The facility's policy and CDC guidance both specify that EBP, including gown and glove use, is required for residents with wounds or indwelling medical devices during high-contact care activities. Additionally, staff failed to perform proper hand hygiene during medication administration. An RN was observed assisting multiple residents with medication and handling medication cups and water without performing hand hygiene between residents, despite the facility's policy requiring hand hygiene before and after each direct resident contact. These lapses in infection control practices were observed across several staff members and care activities, directly contravening facility policy and CDC recommendations.