Failure to Track Infections and Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control guidelines in two main areas: infection tracking and trending, and the implementation of Enhanced Barrier Precautions (EBP). Record review revealed that the facility did not document or track antibiotic use for the months of February and March 2025. The Infection Preventionist confirmed that no tracking occurred during this period, as she only began her role in April. This lack of documentation was inconsistent with the facility's own infection prevention and control policy, which requires ongoing surveillance and reporting of infections and antibiotic usage. Additionally, staff did not consistently follow EBP protocols for residents with chronic wounds. One resident with severe cognitive impairment and an unhealed pressure ulcer had a physician's order and signage indicating the need for staff to wear gowns and gloves during high-contact care. However, a registered nurse provided wound care without donning a gown. Similarly, another resident with pressure and venous ulcers had an order for EBP, but two registered nurses performed wound care without wearing gowns. Both instances were observed and acknowledged by the staff involved, and were not in accordance with the facility's EBP policy.