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F0656
D

Failure to Develop and Implement Care Plan for Enhanced Barrier Precautions

Greenbrae, California Survey Completed on 09-11-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a care plan addressing Enhanced Barrier Precautions (EBP) for a resident admitted with a femur fracture and Alzheimer's Disease. Observation revealed that EBP signage was posted outside the resident's room, indicating specific infection control measures, including the use of gloves and gowns for high-contact care activities. However, staff were observed repositioning the resident in bed without wearing the required personal protective equipment. Interviews with staff confirmed a lack of understanding regarding when to use gloves and gowns for residents on EBP, and the Infection Preventionist acknowledged that moving a resident in bed is considered high-contact care requiring such precautions. Record review showed no documentation in the resident's interdisciplinary notes regarding the initiation or rationale for EBP, nor was EBP included in the resident's baseline or comprehensive care plan. The Infection Preventionist confirmed the absence of EBP documentation and care planning, and stated that the facility did not have a policy or procedure for EBP. The facility's own care planning policy requires comprehensive care plans to address individual resident needs and to be updated as conditions change, but this was not followed in the case of EBP for this resident.

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