Failure to Implement Enhanced Barrier Precautions and Maintain Infection Control Program
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions were properly implemented for a resident with a central IV catheter used for dialysis. During personal care, staff wore gloves but did not use gowns as required, despite the resident's care plan specifying enhanced barrier precautions for the central IV catheter. Observations confirmed that staff did not wear gowns while handling the resident's IV site, and only gloves were available in the resident's room. Staff indicated they believed gowns were unnecessary if the IV insertion site was covered, and there was a lack of accessible personal protective equipment beyond gloves. Additionally, the facility did not maintain an adequate infection surveillance and antibiotic stewardship program. The infection control program had only recently begun using the McGeer criteria, and there was no current enhanced barrier precautions policy in place, only informal guidance. Multiple staff changes in the infection preventionist role occurred over the past year, and some infection control policies had not been reviewed or updated annually as required. Documentation showed gaps in the implementation and oversight of infection prevention and control measures, including incomplete antibiotic stewardship and outdated policies.