Failure to Follow Enhanced Barrier Precautions During High-Contact Care Activities
Penalty
Summary
The facility failed to implement and maintain its infection prevention and control program as required, specifically regarding Enhanced Barrier Precautions (EBP) for two residents. For one resident with an indwelling urinary catheter, two CNAs transferred the resident from a wheelchair to the bathroom using a sit-to-stand machine and assisted with personal care activities, including moving the catheter bag and removing clothing, without wearing gloves or gowns. Both CNAs acknowledged after the fact that they were aware of the EBP requirements and should have worn appropriate PPE during these high-contact care activities, as indicated by the signage and care plan. In a separate incident, a resident with multiple wounds, including a pressure ulcer and venous ulcers, was observed during a wound dressing change. The Interim DON removed the resident's bandage and border dressing without wearing a gown, only donning gloves after handling the resident's leg. The Interim DON initially stated that a gown was not required unless there was a positive wound culture or excessive drainage, which contradicted the facility's policy and the expectations confirmed by the Vice President of Clinical and the Nursing Home Administrator, both of whom stated that both gown and gloves are required for wound care under EBP.