Failure to Implement Infection Prevention and Control Measures
Penalty
Summary
The facility failed to implement infection prevention and control measures as required, resulting in multiple deficiencies related to Enhanced Barrier Precautions (EBP) and proper use of personal protective equipment (PPE). Nursing staff did not follow EBP protocols for a resident with an indwelling Foley catheter and wound drain, as there was no EBP signage posted, no PPE caddy available, and staff did not use gowns or face protection during high-contact care activities. The nurse providing wound vacuum care to this resident was unaware of the EBP status and only wore gloves, contrary to the care plan and facility expectations. Housekeeping staff also failed to adhere to EBP requirements by not wearing a gown while cleaning a room under EBP, despite signage indicating the need for precautions. The staff member acknowledged forgetting to wear the gown and noted that gowns were not readily available in the room, requiring retrieval from the supply room. The Director of Nursing confirmed that all staff, including housekeeping, are expected to follow EBP protocols to prevent the spread of infection. Additional deficiencies included improper storage of a resident's nebulizer mask, which was left uncovered on a nightstand instead of being stored in a bag as per facility policy, and a treatment nurse providing wound care to a resident on EBP without wearing a gown. Both nursing and respiratory therapy policies required proper PPE use and equipment storage to prevent infection, but these protocols were not followed during the observed incidents.