Failure to Implement Enhanced Barrier Precautions and Water Management Program
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) as required for residents with wounds or indwelling medical devices, affecting nine residents out of ten reviewed for transmission-based precautions and EBP. Medical record reviews revealed that several residents had conditions such as indwelling Foley catheters, suprapubic catheters, dialysis catheters, PICC lines, feeding tubes, and chronic wounds, all of which necessitate the use of gowns and gloves during high-contact care activities according to CDC guidance. Despite care plans and, in some cases, physician orders indicating the need for EBP, there was a lack of signage, PPE availability, and staff adherence to these precautions throughout the facility. Observations confirmed that only one resident room had signage and PPE indicating isolation precautions, while other rooms with residents requiring EBP had neither. During direct care activities such as wound care, tube feeding, and catheter care, staff members did not don gowns or have access to appropriate PPE, and there was no signage to alert staff to the need for EBP. Interviews with staff, including laundry personnel and CNAs, revealed a lack of awareness and inconsistent practices regarding EBP, with some staff recalling that PPE was previously provided but was no longer being used as required. Additionally, the facility failed to develop and implement a water management program and Legionella risk assessment, as confirmed by the Maintenance Director and Administrator. Despite having a policy and access to a CDC toolkit for Legionella control, no risk assessment or water management plan was in place. This omission had the potential to affect all residents in the facility, as there was no systematic approach to identifying or mitigating risks associated with Legionella in the water system.