Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement its Infection Prevention and Control Program for two of five sampled residents by not ensuring staff followed Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols. Certified Nursing Assistant 1 (CNA 1) removed splints from a resident with multiple pressure ulcers and an indwelling urinary catheter without wearing a protective gown, despite being aware of the requirement due to the resident's wounds and catheter. CNA 1 acknowledged forgetting to don the gown during the care activity. In a separate incident, two other CNAs (CNA 2 and CNA 3) provided dressing care to another resident who had surgical wounds and an indwelling urinary catheter, also without wearing protective gowns. After completing care, both CNAs removed their gloves and exited the resident's room without performing hand hygiene. CNA 2 later stated that they were aware of the EBP requirements but did not see the EBP sign by the resident's room and therefore did not wear the gown. CNA 2 also confirmed the importance of hand hygiene and PPE use for residents with wounds or indwelling devices. Interviews with the Infection Prevention Nurse and the Director of Nursing confirmed that EBP and hand hygiene are required for residents with wounds or indwelling medical devices, and that staff must don PPE and perform hand hygiene before and after resident care. Facility policies reviewed also indicated that EBP applies to all residents with wounds and/or indwelling medical devices, and that hand hygiene must be performed before donning and after doffing PPE, as well as upon entering and exiting resident rooms.