Failure to Implement Enhanced Barrier Precautions and Infection Control Practices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically by not implementing Enhanced Barrier Precautions (EBPs) as required. Staff did not wear appropriate personal protective equipment (PPE), such as gowns, during high-contact care activities for multiple residents with wounds or indwelling medical devices. For example, during wound care for several residents, both the LPN and DON only wore gloves and did not don gowns, despite facility policy and physician orders indicating the need for EBPs. Staff interviews confirmed the lack of gown use and acknowledged the oversight. Additionally, the facility did not consistently use signage or indicators outside resident rooms to identify those requiring EBPs. The facility's policy called for an orange sticker by the resident's name outside the door to indicate EBP status, but observations revealed that several residents who required EBPs due to wounds, indwelling catheters, dialysis access, or feeding tubes did not have any such indicator. Staff interviews further confirmed that the required signage was missing for these residents, and some staff were unaware of which residents were on EBPs. The facility also failed to maintain proper infection control practices during catheter care. In one instance, a CNA performed catheter care by wiping towards the insertion site and did not change gloves after the task, subsequently touching the resident's gown, bed linens, and rails with contaminated gloves. This improper technique was confirmed by facility leadership during interviews. These failures were observed across multiple residents with significant medical histories, including vascular ulcers, pressure injuries, indwelling catheters, dialysis access, and feeding tubes.