Failure to Implement Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to implement infection control practices for multiple residents, specifically by not initiating Enhanced Barrier Precautions (EBPs) for residents with wounds, indwelling medical devices, or infections. Several residents were identified as having conditions such as chronic wounds, PICC lines, wound vacs, MRSA infections, and other indwelling devices, all of which required EBPs according to facility policy. Observations and interviews confirmed that there was no EBP signage posted, and personal protective equipment (PPE) was not made available outside or inside the rooms of these residents, despite physician orders and policy requirements. Staff interviews, including those with licensed nurses and the Infection Preventionist (IP), confirmed that EBPs were not implemented as required for residents with wounds, indwelling devices, or infections. The IP and Director of Nursing (DON) acknowledged that the facility's EBP policy was not followed, and that residents who should have been on EBPs were not provided with appropriate signage or PPE. This lapse was observed across multiple residents, each with specific medical needs that warranted EBPs, such as open wounds, wound vacs, PICC lines, and active infections. Additionally, a Certified Nurse Assistant (CNA) was observed passing lunch trays to several residents without performing hand hygiene between residents. The CNA admitted to not following hand hygiene protocols, and the IP confirmed that staff were expected to perform handwashing or sanitizing between serving meals. The facility's hand hygiene policy required the use of alcohol-based hand rub or soap and water before and after handling food or assisting residents with meals, but this protocol was not followed during the observed meal service.