Failure to Follow Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow proper infection control practices during incontinence care for a resident with mild intellectual disabilities, heart failure, and depression. The resident, who required partial to moderate assistance with toileting hygiene and was incontinent of bowel and bladder, was observed lying on a soiled fitted sheet and bed pad. During care, staff changed the resident's incontinence brief before changing the soiled sheets, resulting in the clean brief coming into contact with urine-soiled bedding. Both the CNA and RN involved acknowledged that the clean brief was in contact with soiled sheets, which was contrary to facility policy and infection control standards. In a separate incident, staff did not implement Enhanced Barrier Precautions (EBP) for a resident with multiple sclerosis, neurogenic bladder, and a suprapubic catheter, who was also quadriplegic and dependent on staff for activities of daily living. Despite the care plan and facility policy requiring staff to wear gowns and gloves during high-contact care activities such as catheter care, changing briefs, dressing, and transfers, staff were observed performing these tasks without donning gowns. Specifically, staff emptied the resident's catheter bag, changed the resident's brief, assisted with dressing, and transferred the resident using a mechanical lift, all without wearing the required gown, though gloves were used. Interviews with staff and the Director of Nursing confirmed that the expectation was for gowns and gloves to be worn during high-contact care for residents requiring EBP, particularly those with indwelling catheters. Facility policies reviewed also supported these requirements, but observations showed that staff did not consistently adhere to them during the care of the resident with a catheter.