Failure to Implement Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to implement infection control policies during the provision of care to multiple residents requiring Enhanced Barrier Precautions (EBP) due to the presence of pressure ulcers. In several observed instances, nurse aides and nurses did not don gowns as required by EBP protocols when providing incontinence or wound care to residents with chronic wounds. Specifically, two nurse aides provided incontinence care to a resident with a pressure ulcer without wearing gowns, despite signage and available gowns at the door. These staff members also demonstrated a lack of understanding regarding the EBP signage and had not received education on when to use EBP precautions. Additionally, hand hygiene protocols were not followed during resident care activities. In one case, a nurse aide failed to remove soiled gloves and perform hand hygiene after cleaning stool and before touching other items in the resident's environment. In another instance, two nurse aides wore the same gloves throughout the process of cleaning a heavily soiled resident, applying a clean brief, and handling other items in the room, only removing gloves and performing hand hygiene upon exiting. Both staff members acknowledged that they were trained to remove gloves and perform hand hygiene after contact with body fluids but admitted to oversight during the observed care. Nurses also failed to don gowns when providing wound care to a resident on EBP, only correcting their actions after being prompted by a surveyor. Both nurses stated they had been trained on EBP but overlooked the signage and available PPE. Interviews with the Director of Nursing and the Administrator confirmed that staff were expected to follow EBP signage and hand hygiene protocols, including the use of appropriate PPE and hand hygiene after contact with body fluids.