Failure to Implement Enhanced Barrier Precautions and Water Management Protocols
Penalty
Summary
Facility staff failed to implement Enhanced Barrier Precautions (EBP) according to facility policy and CDC guidance for three out of four residents reviewed. In one instance, a nurse performed nephrostomy care and flushed nephrostomy tubes for a cognitively intact female resident with multiple comorbidities, including obstructive uropathy and wounds, without donning a gown as required. The resident reported that staff inconsistently wore gowns during her care. The nurse stated she did not believe a gown was necessary unless there was splashing, despite facility policy requiring gown and glove use for high-contact care. Another resident with chronic kidney disease and a hemodialysis catheter was repositioned and checked for wounds by a CNA who wore gloves but not a gown, under the mistaken belief that the resident was no longer on precautions, despite active EBP orders. A third resident with a stage 3 pressure ulcer received wound care from a nurse who wore gloves but not a gown and was unaware of EBP requirements, having not received facility education on the policy. Additionally, the facility did not maintain an active and ongoing plan to reduce the risk of Legionella and other opportunistic pathogens in premise plumbing. Multiple janitors' sinks and spa tubs throughout the facility were observed with issues such as brown or discolored water, stagnant water lines, and lack of flushing schedules. Some sinks did not dispense water from certain handles, indicating stagnant lines, and some tubs and sinks were not regularly used or flushed. The Director of Facilities confirmed that not all areas were on a flushing schedule and that the facility did not routinely test for residual disinfectants in the water supply, despite having a test kit available. Review of facility policies confirmed that EBP requires gown and glove use for high-contact activities for residents with wounds or indwelling devices, and that the water management program requires control measures, testing protocols, and documentation for water safety. However, staff interviews and observations revealed gaps in knowledge, inconsistent implementation of precautions, and lack of adherence to water management protocols.