Failure to Follow Enhanced Barrier Precautions and Infection Control Practices
Penalty
Summary
The facility failed to adhere to established infection prevention and control practices, specifically regarding Enhanced Barrier Precautions (EBP) across all five resident units. Facility policy required the use of gowns and gloves for high-contact care activities involving residents with chronic wounds, indwelling devices, or colonization/infection with multi-drug resistant organisms (MDROs). Observations revealed that staff did not don appropriate personal protective equipment (PPE), such as gowns and gloves, when providing wound care to a resident with a chronic stage three pressure ulcer who was under EBP. The staff member also failed to perform hand hygiene before the procedure and did not change gloves or wash hands after removing a soiled dressing, contrary to facility policy. Interviews with staff confirmed these lapses in following EBP protocols. Additionally, PPE was not readily available at the doorways or hallways for rooms housing residents requiring EBP, including those with chronic wounds, indwelling catheters, tube feedings, and other medical devices. During medication administration, an LPN was observed wearing gloves while preparing medications but touched multiple surfaces and personal items without changing gloves, then handled medications directly with the same gloves. The LPN also picked up dropped medications and placed them into the medication cup without changing gloves. Staff interviews confirmed awareness of the correct procedures but acknowledged the failures to follow them during the observed events.