Failure to Adhere to Enhanced Barrier Precautions and Laundry Cross-Contamination Prevention
Penalty
Summary
Staff failed to consistently don appropriate Personal Protective Equipment (PPE) while providing care to residents under Enhanced Barrier Precautions (EBP) and did not follow proper procedures to prevent cross contamination in the laundry area. Certified Nursing Assistants (CNAs) were observed transferring and repositioning residents in EBP rooms without wearing gowns, despite EBP signage and care plans specifying the need for gown and glove use during high-contact care activities such as transferring, feeding tube care, and changing linens. The CNAs involved stated they did not believe gowns were required for transfers, even though their education and the posted EBP instructions indicated otherwise. A physical therapist was also observed providing therapy to a resident in an EBP room while only wearing gloves and no gown, with her uniform and arms coming into contact with the resident's bed. The therapist admitted to becoming desensitized to the EBP signage and not consistently wearing gowns as required. The residents involved had significant care needs and were dependent on staff for transfers and repositioning. Their care plans and physician orders documented the use of EBP due to conditions such as gastrostomy tube feeding, indwelling catheters, and wounds, all of which increase the risk of infection transmission. The facility's policies and posted EBP signs clearly instructed staff to wear gowns and gloves during high-contact care activities for these residents. Despite this, staff did not adhere to these requirements during observed care activities. Additionally, in the laundry area, a laundry aide was observed moving a dirty linen bin past a cart containing clean linens, contrary to facility policy and training that require separation of clean and soiled items to prevent cross contamination. The laundry aide acknowledged awareness of the correct procedure but stated she was rushing and forgot to move the clean linen cart out of the way before bringing in the soiled bin. Interviews with supervisory staff confirmed that all staff had been educated on EBP and laundry procedures, and that the expectation was for strict adherence to these protocols.