Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to maintain its infection prevention and control program for a resident who was under Enhanced Barrier Precautions (EBP) due to a physician's order related to a colostomy. The resident, who required substantial assistance with activities of daily living and did not have the capacity to make decisions, had signage indicating EBP outside their room. Despite this, a Certified Nursing Assistant (CNA) entered the resident's room and provided personal care involving direct physical contact without donning a gown, as required by the facility's policy and procedure for EBP. During interviews, the CNA acknowledged forgetting to wear a gown and confirmed that it was a requirement to wear both gloves and a gown before providing personal care to residents on EBP. The Infection Preventionist also stated that staff were expected to wear gowns during high-contact care for residents on EBP to prevent the transmission of infectious microorganisms. The facility's policy specified that gowns and gloves must be used during high-contact resident care activities, such as dressing, bathing, and providing hygiene, to reduce the spread of multidrug-resistant organisms (MDROs).
Plan Of Correction
Ftag=880 Infection Prevention & Control Immediate correction action: On 05/02/25, DON/DSD provided CNA 9 a 1:1 in-service, re-training, and re-education on policy of EBP and infection prevention program. Identification of others at risk: DON/IP made random rounds on 05/02/2025-05/10/2025 on EBP rooms to ensure nursing staff (CNA, LVN, RN) are wearing appropriate PPE on high contact care residents. No other nursing staff were found with the same deficient practice. Process to prevent recurrence: In-services were provided by the DON/IP on 05/02/2025 and 05/20/2025 on policy on infection prevention control program to reinforce use of PPEs on high contact care residents on EBP and ensure nursing staff understand and follow EBP guidelines. Monitoring process: The DON/IP will conduct random weekly rounds on high contact care residents on EBP rooms to ensure staff wear appropriate PPE and follow infection control prevention program x3 months. Completion date: 5/20/2025