Failure to Implement Enhanced Barrier Precautions and Maintain Infection Control
Penalty
Summary
The facility failed to ensure proper implementation of enhanced barrier precautions (EBP) and infection control practices during wound care and urinary catheter care, as well as during the transport of clean laundry. During wound care for a resident with a stage four pressure ulcer and severe cognitive impairment, an LPN did not wear a gown as required by the facility's EBP policy, and there was no signage indicating the need for EBP near the resident's room. The LPN believed that only gloves were necessary for wound care, and the facility did not utilize signage to indicate when EBP was required. In multiple instances of urinary catheter care, staff did not follow EBP protocols. One CNA wore multiple pairs of gloves at once and failed to change gloves during care, based on misinformation from an online video, and did not use a gown. Another LPN and two CNAs provided catheter care and flushing without wearing gowns, and the LPN failed to perform hand hygiene when changing gloves or after removing gloves. The staff relied on verbal communication or personal knowledge to determine when EBP was needed, rather than consistent signage or clear protocols. Additionally, the facility did not maintain infection control standards during the transport of clean laundry. The laundry staff was observed multiple times transporting clean clothes uncovered to resident rooms and was unaware that linens were supposed to be covered. The infection preventionist confirmed that clean clothes should be covered during transport.