Failure to Implement Infection Control Protocols and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper infection prevention and control protocols for multiple residents, specifically regarding enhanced barrier precautions (EBP), injection practices, and the handling of soiled shared equipment. For three residents requiring EBP due to wounds or surgical sites, there were lapses in the use of personal protective equipment (PPE), signage, and care plan documentation. One resident with a deep tissue injury to the left heel had a care plan indicating the need for EBP, but no interventions were listed, and the EBP signage was inconsistently posted. Another resident with a right foot surgical incision had orders and care plans specifying EBP, but staff were observed providing high-contact care without donning the required PPE, and the EBP sign was missing until after surveyor intervention. A third resident with a coccyx wound had no EBP signage or care plan documentation, and an LPN provided direct care without PPE, stating she was unaware of the EBP requirement. Additionally, infection control practices during medication administration were not followed. A nurse was observed preparing and administering an insulin injection without performing hand hygiene or wearing gloves, and later reported that she did not typically use gloves for injections, nor was she trained to do so. This practice deviates from standard infection control protocols and increases the risk of cross-contamination. The facility also failed to ensure that shared equipment was properly cleaned between uses. A hoyer lift was observed in the hallway with a resident grasp cover that had dried, soiled material, indicating it had not been cleaned after use. These deficiencies collectively increased the potential for the spread of infection, bacterial harborage, cross-contamination, and disease transmission among residents.