Failure to Implement Enhanced Barrier Precautions and Equipment Disinfection
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding the use of enhanced barrier precautions (EBP) and proper cleaning of medical equipment. Observations revealed that staff did not consistently use required personal protective equipment (PPE), such as gowns and gloves, during high-contact care activities for residents with indwelling medical devices or wounds. For example, nurse aides provided bathing and incontinence care to a resident dependent on tube feeding without wearing gowns, despite care plan interventions specifying EBP. Additionally, there was no signage indicating EBP outside the rooms of residents requiring such precautions, and staff reported relying on signage to know when PPE was necessary. Further deficiencies were observed in the cleaning and disinfection of medical equipment. Multiple licensed nurses and registered nurses used a sphygmomanometer to check blood pressure on several residents without disinfecting the device between uses. This occurred even for residents on EBP, and staff confirmed at the time of observation that the equipment was not cleaned as required. The lack of proper disinfection was noted during medication administration and routine care activities. Interviews with staff, including nurse aides, licensed nurses, and the Assistant Director of Nursing (ADON), revealed gaps in knowledge and adherence to infection control protocols. Some staff were unaware of the need for PPE in the absence of signage, and EBP signage was found to be inaccessible, locked in the ADON's office. The infection preventionist indicated that unit managers were responsible for posting EBP signage, but this was not consistently done, leading to staff not following established infection control procedures.