Failure to Implement Enhanced Barrier Precautions and Infection Control Protocols
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observations, interviews, and record reviews involving two residents. For one resident with a Foley catheter and a physician's order for Enhanced Barrier Precautions (EBP), there was no EBP signage or personal protective equipment (PPE) available outside the room, and staff were unaware of the resident's need for EBP. Multiple staff members, including LPNs, RNs, and CNAs, were either unsure if the resident had a catheter or did not know the required precautions. Staff were observed entering and exiting the resident's room without performing required hand hygiene, and there was no evidence that EBP protocols were being followed during the survey period. Another resident, who had both a Foley catheter and a PEG tube, was placed on EBP, but staff did not consistently adhere to EBP protocols during high-contact care activities. During observed care, CNAs failed to wear gowns while performing dressing, incontinence care, and transfers, despite the presence of EBP signage and PPE outside the room. Additionally, hand hygiene was inconsistently performed, and equipment such as a mechanical lift was not disinfected between uses. The resident's care plan did not document the need for EBP related to the presence of a Foley catheter and PEG tube, despite physician orders. The facility's own infection control policy requires the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices, such as Foley catheters and PEG tubes, regardless of MDRO colonization status. However, staff interviews and direct observations revealed a lack of knowledge and inconsistent implementation of these precautions. The failure to follow established protocols and physician orders for EBP was evident in both the lack of appropriate signage and PPE, as well as in the actions of staff during resident care.