Failure to Implement Enhanced Barrier Precautions and Proper Infection Control Practices
Penalty
Summary
Surveyors identified that the facility failed to implement and follow Enhanced Barrier Precautions (EBP), proper hand hygiene, and appropriate use of Personal Protective Equipment (PPE) for residents requiring infection control measures. One resident with severely impaired cognition and an unstageable sacral pressure injury, who also had a confirmed Vancomycin-Resistant Enterococci (VRE) infection and was on strict contact isolation, received care from an LPN who only wore gloves and did not don a gown as required. The LPN acknowledged during interview that a gown should have been worn in addition to gloves. Another resident with moderately impaired cognition and total incontinence of bowel and bladder was observed receiving incontinence care from a CNA who failed to change gloves during the care process. The CNA touched multiple surfaces in the resident's environment, including the bed rail, nightstand, sheets, trash bag, and pillow, with contaminated gloves, resulting in cross-contamination. The CNA admitted to not changing gloves and recognized that this practice led to contamination of the environment. A third resident with a sacral pressure ulcer, chronic obstructive pulmonary disease, and benign prostatic hyperplasia received wound care from a treatment nurse who entered the room with gloves already on, did not wear a gown, and failed to perform hand hygiene between glove changes. The nurse's body brushed against the resident's bed during the procedure, and she later acknowledged that hand hygiene and gown use were required due to the resident being on EBP. Facility leadership confirmed expectations for PPE use and hand hygiene, but the facility did not have a specific policy on EBP, instead referencing CDC guidelines.