Failure to Implement Effective Infection Control with Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, specifically regarding the use of personal protective equipment (PPE) with enhanced barrier precautions for two residents. For one resident with a history of sepsis, C. difficile, MRSA, and ESBL, observations revealed that staff, including a licensed nurse and therapy staff, did not consistently wear the required PPE such as gowns and gloves during high-contact care activities, despite signage and care plans indicating the need for enhanced barrier precautions. Interviews with staff and administration showed confusion and lack of awareness regarding the resident's current precaution status and the appropriate use of PPE, with some staff believing only gloves were necessary or being unaware of the requirements altogether. Another resident with an indwelling catheter also required enhanced barrier precautions, as indicated by door signage. However, a nurse aide was observed providing care without wearing a gown and later admitted to being unaware that a gown was required. These failures were identified through direct observation, review of clinical records, and staff interviews, demonstrating a lack of adherence to established infection control policies and procedures for residents requiring enhanced barrier precautions.