Failure to Implement Enhanced Barrier Precautions for Residents with Wounds and Indwelling Devices
Penalty
Summary
Surveyors identified that the facility failed to implement appropriate enhanced barrier precautions (EBP) for three of four residents reviewed for infection control concerns. According to the CMS memo on EBP, nursing facilities are required to use gowns and gloves during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their multidrug-resistant organism status. The facility's own policy also required EBP for residents with wounds or indwelling devices, including posting EBP signage and donning gowns and gloves for high-contact activities such as dressing, transferring, changing linens, providing hygiene, and device care. For one resident with a urinary catheter and a stage IV pressure ulcer, staff were observed transferring the resident and changing her incontinence brief without donning isolation gowns, despite an EBP sign being posted for her bed. Similarly, another resident with a wound requiring daily treatment did not have EBP signage posted for her bed, and staff only used gloves, not gowns, during high-contact care activities such as transferring, changing briefs, and changing linens. A third resident with nephrostomy tubes and multiple wounds also did not have EBP signage for her bed, and staff were observed assisting with transfers without wearing isolation gowns. In each case, staff interviews confirmed a lack of awareness or implementation of EBP requirements for these residents. The surveyor discussed these findings with facility leadership, including the Nursing Home Administrator and Director of Nursing, confirming that the observed failures to implement EBP were inconsistent with both CMS guidance and the facility's own policies. The deficiencies were documented based on direct observation, clinical record review, and staff interviews, and were not limited to a single staff member or shift, but rather reflected a broader failure to consistently apply EBP for residents at risk.
Plan Of Correction
The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction. 1. Residents #1 and #2 had the Enhanced Barrier Precaution signs corrected at the time of the survey. Residents #1, #2, and #3 had no negative outcome from EBP personal protective equipment not worn during the care that was provided during surveyor observation. 2. An initial audit will be conducted of residents that meet the Enhanced Barrier Precautions by the Director of Nursing/designee to ensure signage and personal protective equipment is in place. An initial audit of residents on EBP will be conducted to ensure staff on each shift are donning the appropriate PPE to complete the care he/she is providing. Corrections will be made as needed. The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction. 1. Residents #1 and #2 had the Enhanced Barrier Precaution signs corrected at the time of the survey. Residents #1, #2, and #3 had no negative outcome from EBP personal protective equipment not worn during the care that was provided during surveyor observation. 2. An initial audit will be conducted of residents that meet the Enhanced Barrier Precautions by the Director of Nursing/designee to ensure signage and personal protective equipment is in place. An initial audit of residents on EBP will be conducted to ensure staff on each shift are donning the appropriate PPE to complete the care he/she is providing. Corrections will be made as needed. 3. Education will be provided to the facility licensed nursing staff regarding facility procedure Enhanced Barrier Precautions. 4. Audits will be conducted weekly x four and monthly x three by the Director of Nursing/designee of residents that meet the Enhanced Barrier Precautions to ensure signage is in place. A random audit of five residents on EBP will be conducted by the Director of Nursing designee weekly x four and monthly x three to ensure staff on each shift are donning the appropriate PPE to complete the care he/she is providing. Corrections will be made as needed. Results of audits will be reported at the Quality Assurance Performance Improvement meetings.