Failure to Adhere to Enhanced Barrier Precautions and Infection Control Practices
Penalty
Summary
Surveyors observed that an LPN failed to follow Enhanced Barrier Precautions (EBP) by not donning a gown, as required, while administering medications through a gastric tube to a resident with multiple diagnoses including encephalopathy, diabetes mellitus type two, hypertensive heart disease with heart failure, and gastrostomy status. The resident's room had signage and supplies indicating the need for EBP, and both facility policy and staff training specified the use of gloves and gowns for high-contact care involving indwelling medical devices. The LPN only wore gloves during the procedure, which was confirmed during an interview at the time of observation. Additionally, the same LPN did not clean a wrist blood pressure monitor between use on two residents, instead placing the soiled device on the medication cart and reusing it without disinfection. Both residents had significant medical histories, including chronic kidney disease, palliative care, dementia, and heart failure. Facility staff training emphasized the importance of cleaning shared medical devices between residents. In a separate incident, a wall-mounted fan in the clean laundry area was found to be visibly dirty and blowing air toward clean linen, with accumulated dirt observed dispersing toward the linen. The housekeeping supervisor confirmed the fan's condition and its use in the clean area.