Failure to Implement Infection Control Protocols for Residents on Enhanced Barrier Precautions and in Laundry Area
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols for two residents on Enhanced Barrier Precautions (EBP) and in the facility's laundry area. For one resident with dementia and multiple pressure ulcers, a certified nurse assistant provided care while only wearing gloves and removed her isolation gown before completing all care activities, despite an active EBP order. Interviews with nursing staff confirmed that the EBP protocol required the use of both gown and gloves for all high-contact care activities, and that the gown should not have been removed until care was finished and before leaving the room. For another resident with end stage renal disease and a central venous catheter, there was no EBP signage or PPE cart outside the room, despite an active EBP order. A nurse confirmed that staff should have access to and use appropriate PPE, including gown, gloves, and mask, during direct care for this resident. Facility policy required that EBP signage and PPE be readily available and that staff, residents, and visitors be educated on EBP requirements. In the laundry area, a cart of clean linen was placed in the dirty area next to a sink clogged with dark brown water, and there was no signage to distinguish clean and dirty areas. The housekeeping supervisor and infection preventionist nurse both stated that clean linen should be stored in the clean area to prevent cross-contamination, and that the sink should remain unclogged to prevent the spread of bacteria. Facility policy required that soiled and clean linens not be stored together and that laundry equipment problems be reported and addressed promptly.
Plan Of Correction
Immediate Corrective Action for resident affected by this deficient practice: On 6/13/25, DSD applied Enhance Barrier Precautions signage and isolation cart to outside of room 119. On 6/13/25, Housekeeping Supervisor placed signs to indicate clean and dirty areas in Laundry Room. Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken: DSD with DON rounded and found no other resident affected by the same deficient practice. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: On 6/13/25, CNA 5 was given 1:1 by DSD in-service to render care with Enhanced Barrier Precautions (gown and gloves) to prevent cross contamination of infections. In-service was done by DSD to all licensed Nurses and Certified Nurses Assistants on 06/15/25 that includes to wear gown and gloves when rendering care with Residents who have indwelling catheters, open skin areas, gastronomy tubes, hemodialysis shunt sites, etc., to prevent the spread of infection. DON gave a 1:1 in-service on 06/13/25 with Infection Preventionist regarding prevention and infection control. On 6/13/25, the DON gave the Infection Preventionist an Infection Control Clinical Rounds daily check-off list and will do rounds. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Starting 7/01/25, DON or designee will review performance and report to the Administrator and report to QAPI monthly meetings for compliance. Monthly QA discussion will occur for 3 months. Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken: DSD with DON rounded and found no other resident affected by the same deficient practice. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: On 6/13/25, CNA 5 was given 1:1 by DSD in-service to render care with Enhanced Barrier Precautions (gown and gloves) to prevent cross contamination of infections. In-service was done by DSD to all licensed Nurses and Certified Nurses Assistants on 06/15/25 that includes to wear gown and gloves when rendering care with Residents who have indwelling catheters, open skin areas, gastronomy tubes, hemodialysis shunt sites, etc., to prevent the spread of infection. DON gave a 1:1 in-service on 06/13/25 with Infection Preventionist regarding prevention and infection control. On 6/13/25, the DON gave the Infection Preventionist an Infection Control Clinical Rounds daily check-off list and will do rounds.