Failure to Follow Enhanced Barrier Precautions and Infection Control Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to Enhanced Barrier Precautions (EBP) and proper infection control practices for two of five sampled residents. For one resident with a PEG tube and multiple complex diagnoses, a physician order required EBP, including the use of a protective gown during high-contact care. However, during an observed dressing change of the PEG tube, the LPN did not wear a protective gown as required. Another resident with a history of diabetes, chronic kidney disease, foot ulcers, and a sacral wound had physician orders for EBP and specific wound care protocols. During wound care and incontinence care, the LPN and a CNA failed to don protective gowns before providing high-contact care, including wound dressing changes and handling soiled linens. The LPN was observed leaning against soiled bed linens, wearing a bracelet with dangling charms that came into contact with soiled materials, and not performing hand hygiene between glove changes or between dirty and clean tasks. The same section of gauze and betadine swab was used on multiple wound areas, contrary to accepted infection control principles. Both the LPN and CNA were observed with their unprotected upper bodies in contact with soiled linens and the resident during care. The LPN confirmed during an interview that she did not follow required infection control practices, including the use of a protective gown, proper hand hygiene, and removal of jewelry before care. These actions directly contributed to the facility's failure to prevent the potential development and transmission of communicable diseases and infections.